Modified Selective Neurectomy

Azizzadeh, Babak; Hjelm, Nikolaus

doi:10.1016/j.fsc.2021.03.005

Cited by 11 publications

(17 citation statements)

References 20 publications

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“…A natural smile can be achieved by reducing the action of synkinetic muscles and creating a balance between smile elevators and antagonists as described by the MSN. 21,36,37 It is important to note the great variability among techniques for SN. While most authors describe identification of facial nerve branches intraoperatively using a nerve stimulator, Kim and colleagues have described the use of local anesthetic to inject specific muscles contributing to synkinesis preoperatively.…”

Section: Discussionmentioning

confidence: 99%

“…Surgical options include selective myectomy, selective neurectomy (SN), cross-facial nerve grafting, nerve substitution, and finally, free gracilis muscle transfer (FGMT). [33][34][35][36][37][38] SN is one tool in the management of synkinesis that can be used in conjunction with other procedures. Coleman first described neurectomy of proximal facial nerve branches in patients with hemifacial spasm in 1937.…”

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confidence: 99%

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Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review

et al. 2022

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Background: Synkinesis is commonly encountered after flaccid facial paralysis and can have a detrimental impact on a patient’s life. First line treatment of synkinesis is chemodenervation with Botulinum toxin (Botox) and neuromuscular retraining. Surgical options include selective myectomy, selective neurectomy (SN), cross-facial nerve grafting, nerve substitution, and free gracilis muscle transfer (FGMT). Data on surgical management of synkinesis using selective neurectomy is limited. Evidence Review PubMed, Embase, Cochrane CENTRAL, Cochrane Neuromuscular Register, Clinicaltrials.gov, and WHO ICTPR were searched using a comprehensive keyword strategy in accordance with PRISMA guidelines. All English-only texts published in the last 20 years were included. Two independent investigators reviewed 906 abstracts and 7 studies met inclusion criteria. Demographics, etiology of paralysis, time to surgery, and primary outcomes studied were collected. Findings A total of 250 patients were included across 7 studies. In 6 out of 7 studies, Botox was used prior to surgical intervention. Two studies showed significant reduction in Botox dosage postoperatively, while one study showed no difference. Other primary outcomes included the House-Brackman Score, palpebral fissure width, eFACE score, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Three studies showed significant improvement in the eFACE score, two studies showed significant improvement in the FaCE scale, while one study showed improvement in quality of life measured by the SAQ. Conclusions Selective neurectomy can be considered as an adjunct to other management options including neuromuscular retraining, Botox, selective myectomy and reanimation procedures. While there is great heterogeneity of study design in the studies included, many cohorts showed improvement in facial symmetry, facial function, and quality of life. There remains a great gap in knowledge in this subject matter and a need for large well designed prospective studies comparing this technique to other management options.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review

et al. 2022

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“…Notably, the nerve branch to the depressor labii inferioris muscle must be identified and preserved, as this muscle is critically important for smile. A platysmal myotomy is performed, and the SMAS, platysma and subcutaneous layers are closed in a standard fashion [17 ]. Selection of patients is of utmost importance given the risks associated with nerve sacrifice.…”

Section: Reviewmentioning

confidence: 99%

“…Understanding that variations exist, Azizzedeh's modified selective neurectomy (MSN) is perhaps the best known and is thus described [17 ▪ ]. The approach begins with a retrotragal rhytidectomy incision, without systemic or local paralytic, and with facial nerve stimulation capabilities throughout the case.…”

Section: Reviewmentioning

confidence: 99%

“…Azizzadeh describes the ideal patient for modified selective neurectomy, which excludes those with flaccid facial paralysis or malignancy. Ideal candidacy includes those with “stable synkinesis over time, active zygomatic major/minor muscles, and intact distal branches of the facial nerve” [17 ▪ ]. There are two major patient populations that are historically represented in the literature: those with periocular synkinesis and those with a synkinetic smile [16 ▪▪ ].…”

Section: Reviewmentioning

confidence: 99%

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Selective neurectomy for nonflaccid facial palsy

Ovaitt

Chweya

Flynn

2023

Current Opinion in Otolaryngology &Amp; Head &Amp; Neck Surgery

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Purpose of review To review the evolving role of selective neurectomy in the management of patients with synkinesis including the history of selective neurectomy, operative techniques, and clinical outcomes. Recent findings Modified selective neurectomy alone or in conjunction with other procedures achieves more durable outcomes based on objective measures such as time to recurrence of symptoms and units of botulinum toxin required postoperatively. This is also reflected on patient reported quality of life outcome measures. Regarding operative technique, lower rates of oral incompetence are reported with division of an average of 6.7 nerve branches as opposed to more branches. Summary Chemodenervation has long been the mainstay of treatment in facial synkinesis, but in recent years, the paradigm has begun to shift in favor of incorporating interventions with more durable outcomes such as modified selective neurectomy. Modified selective neurectomy is often performed with other simultaneous surgeries such as nerve transfer, rhytidectomy, lid surgery and static facial reanimation primarily to address periocular synkinesis and synkinetic smile. The outcomes have been favorable with improvement in quality-of-life measures and a decrease in botulinum toxin requirements.

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Does supercharging with cross‐face nerve graft enhance smile in non‐flaccid facial paralysis patients undergoing selective neurectomy?

Kaufman Goldberg,

Trzcinski,

McGonagle

et al. 2023

Microsurgery

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BackgroundCross face nerve grafting (CFNG) is a well‐established nerve transfer technique in facial reanimation; however, no study has assessed outcome of supercharging the smile with CFNG in patients with synkinesis. The goal of this study was to examine the smile outcome in non‐flaccid facial paralysis (NFFP) patients after supercharging with CFNG during selective neurectomy.MethodsNFFP patients who underwent CFNG with end‐to‐side coaptation to a smile branch on the paralyzed side during selective neurectomy were retrospectively identified and their charts were reviewed. Pre‐operative and post‐operative facial function was assessed with the electronic clinician‐graded facial function tool (eFACE), and an automated computer‐aided facial assessment tool (Emotrics). Smile metrics were compared pre‐operatively, in early post‐operative time (EPO, <6 months), and late post‐operative time (LPO, >9 months) when CFNG contribution would be expected.ResultsThirteen cases were performed between June 2019 and December 2021. No objective smile metrics improved following supercharging with CFNG. Oral commissure excursion improved by 1.23 points in eFACE (p = .812), and by 0.84 in Emotrtics (p = .187) from EPO to LPO. EFACE dynamic score was improved by 0.08 points from EPO to LPO (p = .969).ConclusionsUsing CFNG for supercharging the smile during selective neurectomy in NFFP patients may not enhance smile. Longer term results following supercharging and long term natural history of selective neurectomy should be assessed.

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Modified Selective Neurectomy

Cited by 11 publications

References 20 publications

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review

Selective neurectomy for nonflaccid facial palsy

Does supercharging with cross‐face nerve graft enhance smile in non‐flaccid facial paralysis patients undergoing selective neurectomy?

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