Publications by authors named "Samir Mardini"

166 Publications

Predictors of favorable outcome following hypoglossal-to-facial nerve anastomosis for facial nerve palsy: a systematic review and patient-level analysis of a literature-based cohort.

J Neurosurg 2022 Aug 12:1-9. Epub 2022 Aug 12.

1Neuro-Informatics Laboratory, Mayo Clinic, Rochester.

Objective: Facial nerve palsy is a debilitating condition that can arise from iatrogenic, traumatic, or congenital causes. One treatment to improve function of the facial muscles after facial nerve injury is hypoglossal-to-facial nerve anastomosis (HFA). HFA's efficacy and predictors of its success vary in the literature. Here, the authors present a patient-level analysis of a literature-based cohort to assess outcomes and investigate predictors of success for HFA.

Methods: Seven electronic databases were queried for studies providing baseline characteristics and outcomes of patients who underwent HFA. Postoperative outcomes were measured using the House-Brackmann (HB) grading scale. A change in HB grade of 3 points or more was classified as favorable. A cutoff value for time to anastomosis associated with a favorable outcome was determined using the Youden Index.

Results: Nineteen articles with 157 patients met the inclusion criteria. The mean follow-up length was 27.4 months, and the mean time to anastomosis after initial injury was 16 months. The end-to-side and end-to-end anastomosis techniques were performed on 84 and 48 patients, respectively. Of the 130 patients who had available preoperative and postoperative HB data, 60 (46.2%) had a favorable outcome. Time from initial injury to anastomosis was significantly different between patients with favorable and unfavorable outcomes (7.3 months vs 29.2 months, respectively; p < 0.001). The optimal cutoff for time to anastomosis to achieve a favorable outcome was 6.5 months (area under the curve 0.75). Patients who underwent anastomosis within 6.5 months of injury were more likely to achieve a favorable outcome (73% vs 31%, p < 0.001).

Conclusions: HFA is an effective method for restoring facial nerve function. Favorable outcomes for facial nerve palsy may be more likely to occur when time to anastomosis is within a 6.5-month window.
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http://dx.doi.org/10.3171/2022.6.JNS22240DOI Listing
August 2022

Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction.

Ann Thorac Surg 2022 Jun 17. Epub 2022 Jun 17.

Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements.

Methods: This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018.

Results: A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time.

Conclusions: Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.048DOI Listing
June 2022

Gain and loss of TASK3 channel function and its regulation by novel variation cause KCNK9 imprinting syndrome.

Genome Med 2022 06 13;14(1):62. Epub 2022 Jun 13.

Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands.

Background: Genomics enables individualized diagnosis and treatment, but large challenges remain to functionally interpret rare variants. To date, only one causative variant has been described for KCNK9 imprinting syndrome (KIS). The genotypic and phenotypic spectrum of KIS has yet to be described and the precise mechanism of disease fully understood.

Methods: This study discovers mechanisms underlying KCNK9 imprinting syndrome (KIS) by describing 15 novel KCNK9 alterations from 47 KIS-affected individuals. We use clinical genetics and computer-assisted facial phenotyping to describe the phenotypic spectrum of KIS. We then interrogate the functional effects of the variants in the encoded TASK3 channel using sequence-based analysis, 3D molecular mechanic and dynamic protein modeling, and in vitro electrophysiological and functional methodologies.

Results: We describe the broader genetic and phenotypic variability for KIS in a cohort of individuals identifying an additional mutational hotspot at p.Arg131 and demonstrating the common features of this neurodevelopmental disorder to include motor and speech delay, intellectual disability, early feeding difficulties, muscular hypotonia, behavioral abnormalities, and dysmorphic features. The computational protein modeling and in vitro electrophysiological studies discover variability of the impact of KCNK9 variants on TASK3 channel function identifying variants causing gain and others causing loss of conductance. The most consistent functional impact of KCNK9 genetic variants, however, was altered channel regulation.

Conclusions: This study extends our understanding of KIS mechanisms demonstrating its complex etiology including gain and loss of channel function and consistent loss of channel regulation. These data are rapidly applicable to diagnostic strategies, as KIS is not identifiable from clinical features alone and thus should be molecularly diagnosed. Furthermore, our data suggests unique therapeutic strategies may be needed to address the specific functional consequences of KCNK9 variation on channel function and regulation.
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http://dx.doi.org/10.1186/s13073-022-01064-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9195326PMC
June 2022

Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures.

Aesthetic Plast Surg 2022 Jun 1. Epub 2022 Jun 1.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA.

Background: Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position.

Objective: The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions.

Methods: This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity.

Results: The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001.

Conclusion: Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-022-02921-8DOI Listing
June 2022

Facial Transplantation.

Facial Plast Surg Clin North Am 2022 May;30(2):255-269

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA; Essam and Dalal Obaid Center for Reconstructive Transplant Surgery, Mayo Clinic, Rochester, MN, USA; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA. Electronic address:

Facial transplantation is a vascularized composite allotransplantation, which may be considered in patients with extensive and challenging facial defects for which conventional reconstructive approaches fail to provide satisfactory functional and esthetic outcomes. Facial transplantation has the advantage of replacing defective or absent structures with anatomically identical tissues. Facial transplantation may provide functional, esthetic, and psychosocial benefits, but must be weighed against risks such as lifelong immunosuppression. Success is reliant on patient understanding, motivation, consent and compliance, and a multidisciplinary approach with careful team planning and organization. This review highlights the achievements, challenges, and future directions of this rapidly evolving field.
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http://dx.doi.org/10.1016/j.fsc.2022.01.011DOI Listing
May 2022

Virtual Surgical Planning (VSP) in Craniomaxillofacial Reconstruction.

Facial Plast Surg Clin North Am 2022 May;30(2):239-253

Division of Plastic Surgery, Department of Surgery, Obaid Center for Reconstructive Transplant Surgery, Mayo Clinic, MA1244W, 200 First Street Southwest, Rochester, MN 55905, USA. Electronic address:

The complex three-dimensional (3D) anatomy of the craniomaxillofacial skeleton creates a challenge for surgical reconstruction. Advances in virtual surgical planning (VSP) have enhanced reconstructive outcomes in craniomaxillofacial aesthetic and reconstructive surgery. This technology has been especially useful in spatially complex cases due to the ability to visualize and manipulate 3D configurations of the cranium through virtual surgery, printing of stereolithographic models, fabrication of cutting and positioning guides, creation of prefabricated hardware, and refinements of custom implants. In many cases, VSP results in improved accuracy, efficiency, and reduced operative time compared with traditional techniques. As research and indications expand, VSP will continue to be an integral adjunct to the planning and execution of complex craniomaxillofacial surgeries.
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http://dx.doi.org/10.1016/j.fsc.2022.01.016DOI Listing
May 2022

The Fascias of the Forehead and Temple Aligned-An Anatomic Narrative Review.

Facial Plast Surg Clin North Am 2022 May;30(2):215-224

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN 55905, USA. Electronic address:

A thorough understanding of 3-dimensional facial anatomy and its fascial concepts is essential to allow for further development of novel surgical and nonsurgical treatment strategies to increase patient safety and effectiveness. The layered anatomy and its interconnections of the forehead, scalp, and temple is complex and is thus summarized and aligned in a unified nomenclature in this review. The scalp consists of 5 layers, which transition into 8 layers in the forehead and into a total of 13 layers in the temple.
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http://dx.doi.org/10.1016/j.fsc.2022.01.006DOI Listing
May 2022

Cytomegalovirus-related Complications and Management in Facial Vascularized Composite Allotransplantation: An International Multicenter Retrospective Cohort Study.

Transplantation 2022 Apr 6. Epub 2022 Apr 6.

Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT.

Background: There is a paucity of data on the impact of cytomegalovirus (CMV) serostatus and CMV infection on outcomes in facial vascularized composite allotransplantation.

Methods: This international, multicenter, retrospective cohort study presents data on CMV and basic transplant-related demographics, including pretransplant viral D/R serostatus, and duration of antiviral prophylaxis. CMV-related complications (viremia, disease), allograft-related complications (rejection episodes, loss), and mortality were analyzed.

Results: We included 19 patients, 4 of whom received CMV high-risk transplants (D+/R-). CMV viremia was noted in 6 patients (all 4 D+/R- patients and 2 D-/R+), mostly within the first-year posttransplant, shortly after discontinuation of antiviral prophylaxis (median 2 mo). CMV disease occurred in 2 D+/R- patients. The high-risk group experienced relatively more rejection episodes per month follow-up. None of D+/R- patients suffered allograft loss due to rejection (longest follow-up: 121 mo).

Conclusions: D+/R- patients were at increased risk of CMV-related complications. Although a higher number of rejections was noted in this group, none of the D+/R- patients lost their allograft or died because of CMV or rejection. Thus, CMV D+/R- face transplantation can likely be safely performed with prophylaxis, active surveillance, and prompt treatment.
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http://dx.doi.org/10.1097/TP.0000000000004132DOI Listing
April 2022

Microsurgical skills training course and impact on trainee confidence and workload.

J Plast Reconstr Aesthet Surg 2022 07 19;75(7):2135-2142. Epub 2022 Feb 19.

Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.

Introduction: Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery.

Methods: A prospective study of participants in an accredited 5-day microsurgery course over a 3-month period. The confidence and workload of the participants were assessed after the first and final day. The workload was assessed using the validated NASA Task Load Index composed of 6 subscales scored on a 20-point visual analog scale (VAS). Confidence was assessed over 5 dimensions on a 5-point VAS for anastomosis performance, vessels preparation, knot tying, training effectiveness, and future practice of microsurgery.

Results: A total of 31 participants completed the study with 55% reporting some previous microsurgery experience. All confidence dimensions improved significantly after completing the course, regardless of prior experience (p<0.01). Those with prior experience started and finished the course at higher confidence levels in anastomosis performance and vessel preparation than the non-experienced group (p<0.05). Overall workload showed a downward trend (improvement) at the end of the course, but no significant changes in the experienced and non-experienced groups (p>0.05). Most participants scored above the 50% "sustainability threshold" for mental demand, both before (71%) and after the course (73%), however, perceived physical demand significantly reduced, p = 0.01.

Conclusion: The microsurgery course teaches fundamental skills and principles; therefore, it has merit in those who will utilize these skills in their future practice. Although there is increased confidence in skill acquisition, the impact on perceived workload during a short 5-day basic microsurgery course did not significantly change.
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http://dx.doi.org/10.1016/j.bjps.2022.02.004DOI Listing
July 2022

Role of adipose tissue grafting and adipose-derived stem cells in peripheral nerve surgery.

Neural Regen Res 2022 Oct;17(10):2179-2184

Department of Orthopedic Surgery, Division of Microvascular and Hand Surgery, Mayo Clinic, Rochester, MN, USA.

The application of autologous fat grafting in reconstructive surgery is commonly used to improve functional form. This review aims to provide an overview of the scientific evidence on the biology of adipose tissue, the role of adipose-derived stem cells, and the indications of adipose tissue grafting in peripheral nerve surgery. Adipose tissue is easily accessible through the lower abdomen and inner thighs. Non-vascularized adipose tissue grafting does not support oxidative and ischemic stress, resulting in variable survival of adipocytes within the first 24 hours. Enrichment of adipose tissue with a stromal vascular fraction is purported to increase the number of adipose-derived stem cells and is postulated to augment the long-term stability of adipose tissue grafts. Basic science nerve research suggests an increase in nerve regeneration and nerve revascularization, and a decrease in nerve fibrosis after the addition of adipose-derived stem cells or adipose tissue. In clinical studies, the use of autologous lipofilling is mostly applied to secondary carpal tunnel release revisions with promising results. Since the use of adipose-derived stem cells in peripheral nerve reconstruction is relatively new, more studies are needed to explore safety and long-term effects on peripheral nerve regeneration. The Food and Drug Administration stipulates that adipose-derived stem cell transplantation should be minimally manipulated, enzyme-free, and used in the same surgical procedure, e.g. adipose tissue grafts that contain native adipose-derived stem cells or stromal vascular fraction. Future research may be shifted towards the use of tissue-engineered adipose tissue to create a supportive microenvironment for autologous graft survival. Shelf-ready alternatives could be enhanced with adipose-derived stem cells or growth factors and eliminate the need for adipose tissue harvest.
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http://dx.doi.org/10.4103/1673-5374.336870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9083182PMC
October 2022

Clinical and Radiological Safety of Retained Implantable Doppler Devices Used for Free Flap Monitoring.

Plast Surg (Oakv) 2022 Feb 27;30(1):20-24. Epub 2021 Apr 27.

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Introduction: Implantable Doppler devices are reliable adjuncts used for free flap monitoring. Occasionally, the probe/wire is not removed and remains in the soft tissues. The clinical safety of the retained probes and safety and compatibility with magnetic resonance imaging (MRI) have not been studied. We present a series of retained implantable Doppler probes examining clinic outcomes, safety and compatibility with MRI, and effect on MRI image quality.

Methods: A retrospective review was conducted of patients who had an implantable Doppler device for free flap monitoring between July 2007 and August 2018. Routine post-operative imaging was reviewed for all patients to identify incidental findings of a retained probe. A subset of patients with retained implantable Doppler probes who underwent MRI was identified. Magnetic resonance images were reviewed to detect any degradation of image quality.

Results: A total of 323 patients who had an implantable Doppler device placed were reviewed 18 (5.6%) patients were identified with a retained probe and were included in this study. Mean age was 49 years with mean follow-up of 34.4 months. One potential device-related complication occurred in 1 (5.6%) patient. A total of 32 MRI scans were performed in 8 patients with retained devices, including 6 patients who underwent a total of 21 MRIs of the surgical site. There were no complications related to the MRI scans, and we found no significant degradation of image quality.

Conclusion: Retained implantable Doppler probes were not associated with substantial adverse clinical outcomes nor affected MRI image quality of the surgical site.
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http://dx.doi.org/10.1177/22925503211006537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8793759PMC
February 2022

Reply: Using Artificial Intelligence to Measure Facial Expression following Facial Reanimation Surgery.

Plast Reconstr Surg 2022 03;149(3):594e-595e

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.

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http://dx.doi.org/10.1097/PRS.0000000000008867DOI Listing
March 2022

Sternectomy Replacement With 3-Dimensional Printed Composite Porous High-Density Polyethylene.

Ann Thorac Surg 2022 Jan 24. Epub 2022 Jan 24.

Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

A 54-year-old man with a history of type 2 diabetes presented in 2020 for a Bentall procedure after undergoing cardiac surgery complicated by sternal osteomyelitis in 2011. Sternal closure after aortic root replacement included a laparoscopically harvested omental flap to cover the heart. In 2021, multidisciplinary complex sternal reconstruction using a customized 3-dimensional-printed implant based on the patient's computed tomography imaging was performed with compassionate use permission from the Food and Drug Administration. We report the successful entire sternal replacement using a synthetic polyethylene implant.
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http://dx.doi.org/10.1016/j.athoracsur.2021.12.067DOI Listing
January 2022

Reevaluation of the Layered Anatomy of the Forehead: Introducing the Subfrontalis Fascia and the Retrofrontalis Fat Compartments.

Plast Reconstr Surg 2022 Mar;149(3):587-595

From private practice; the Department for Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich; Division of Plastic and Reconstructive Surgery, Mayo Clinic; CH Dermatologia; Department of Radiology and Medical School, University of Belgrade; and Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science.

Background: Novel imaging methods have provided new insights into the layered anatomy of the forehead. This study seeks to critically reevaluate the layered anatomy of the forehead by using ultrasound imaging and cadaveric dissection to provide an accurate anatomical description that can be used to guide safer surgical and minimally invasive frontal procedures.

Methods: This study used ultrasound imaging in a sample of 20 volunteers (12 female and eight male volunteers; aged 35.25 ± 4.2 years; body mass index, 24.28 ± 3.5 kg/m2) and cadaveric dissections of 16 body donors (12 female and four male body donors; aged 72.76 ± 9.5 years) to reevaluate the layered anatomy of the forehead. Layer-by-layer dissections and ultrasound-based measurements of the frontal structures guided conclusions.

Results: The following layered arrangement was identified: layer 1, skin; layer 2, superficial fatty layer; layer 3, suprafrontalis fascia; layer 4, orbicularis oculi and frontalis muscle (same plane); layer 5, a homogenous layer of fat [preseptal fat (in the upper eyelid), retro-orbicularis fat (deep to the orbicularis oculi muscle), and retro-frontalis fat (deep to the frontalis muscle); layer 6, subfrontalis fascia; layer 7, preperiosteal fat within the prefrontal space in the lower forehead and deep compartments in the upper forehead; and layer 8, periosteum.

Conclusions: The results of this study add to the current understanding of the layered arrangement of the forehead. The combination of ultrasound imaging and cadaveric dissections provided evidence for a continuous fatty layer deep to the frontalis muscle.
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http://dx.doi.org/10.1097/PRS.0000000000008826DOI Listing
March 2022

Reply: Using Artificial Intelligence to Measure Facial Expression following Facial Reanimation Surgery.

Plast Reconstr Surg 2022 02;149(2):345e-346e

Division of Plastic Surgery, Department of Surgery, Sidra Medicine, Department of Surgery, Weill Cornell Medicine-Qatar, Doha, Qatar.

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http://dx.doi.org/10.1097/PRS.0000000000008757DOI Listing
February 2022

Seminal Studies in Facial Reanimation Surgery: Consensus and Controversies in the Top 50 Most Cited Articles.

J Craniofac Surg 2021 Dec 20. Epub 2021 Dec 20.

Division of Plastic Surgery, Mayo Clinic, Rochester, MN Department of Plastic Surgery, MD Anderson Cancer Center, Houston, TX Aleppo University, Faculty of Medicine, Aleppo, Syria Mayo Clinic Alix School of Medicine, Rochester, MN Division of Plastic Surgery, Sidra Medicine and Weill Cornell Medical College, Doha, Qatar.

Abstract: Facial paralysis can impair one's ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist.Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.
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http://dx.doi.org/10.1097/SCS.0000000000008436DOI Listing
December 2021

Intraoperative Ultrasound Imaging in Silicone Filler Removal.

J Craniofac Surg 2021 May;32(3):e276-e278

Division of Plastic Surgery.

Abstract: Dermal filler injections, one of the most commonly performed procedures in facial esthetic surgery, are rising in popularity. This has also led to an increase in nonmedical grade filler injections performed by nonmedical personnel, including that of injectable silicone. Surgical removal of silicone fillers is challenging, as the hydrophobic material often disperses within the soft tissue as droplets. This can lead to a systemic inflammatory reaction requiring steroid treatment. MRI localization of the filler material does not enable intraoperative guidance, and palpitation of the material is challenging since the filler droplets are often too small to palpate and located in multiple planes. We present a case demonstrating the advantages of utilizing intraoperative ultrasound to localize and silicone filler material. Utilizing this technique, we were able to achieve a high degree of excision of silicone filler material and the patient was able to stop her previous necessary immunosuppressive steroid regimen successfully.
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http://dx.doi.org/10.1097/SCS.0000000000007196DOI Listing
May 2021

Endoscopic Browlift in Patients With Receding Hairlines.

J Craniofac Surg 2022 Mar-Apr 01;33(2):615-619

Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic.

Abstract: Patients with receding or high hairlines have traditionally been considered unfavorable candidates for endoscopic brow lift as this can further lengthen the hairline. We analyzed outcomes in patients that underwent a novel endoscopic brow lift technique with placement of incisions and anchoring Endotine Forehead Devices (CoApt Systems Inc, Palo Alto, CA, USA) directly at the natural forehead crease lines, in an effort to minimize elevation of the hairline, whereas providing well-hidden scars. We retrospectively reviewed all patients who underwent this new Endotine and incision placement between 2016 and 2020. Preoperative and postoperative photographs of all patients were analyzed to determine the postoperative changes in brow elevation and forehead length proportion (defined as length from cranium to chin).The forehead length proportion was unchanged pre- and post-operatively, with no statistically significant differences noted (P = 0.48). The average brow position elevation ranged from 2.78 mm in the medial location to 5.05 mm in the lateral location. All patients were happy with their appearance and had improved visual fields postoperatively. The forehead scars healed well and were well hidden in forehead rhytids at long term follow-up.This novel endoscopic brow lift technique provides an option to utilize a minimally invasive approach in patients with receding hairline. With this technique, visible scars were minimized, whereas still being able to achieve reasonable brow elevation. Thus, our approach enables long term maintenance of brow elevation with inconspicuous scars in the forehead.
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http://dx.doi.org/10.1097/SCS.0000000000008156DOI Listing
April 2022

The Layered Anatomy of the Nose: An Ultrasound-Based Investigation.

Aesthet Surg J 2022 03;42(4):349-357

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex.

Objectives: The authors sought to describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement.

Methods: A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose utilizing ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature.

Results: In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n = 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% to 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip.

Conclusions: Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared with any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.
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http://dx.doi.org/10.1093/asj/sjab310DOI Listing
March 2022

The Impact of Breast Symmetry on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

Aesthet Surg J 2021 10;41(11):NP1512-NP1518

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany.

Background: The objective assessment of beauty remains challenging despite ongoing research efforts. A new method of objectively determining the aesthetic appeal of body features by analyzing gaze patterns and eye movements has recently been investigated.

Objectives: The objective of this study was to assess, by means of objective eye-tracking technology, differences in the gaze patterns of observers presented with standardized 3-dimensional images showing different degrees of breast asymmetry.

Methods: A total of 83 Caucasian study participants with a mean age of 38.60 (19.8) years were presented with 5 images depicting varying degrees of breast asymmetry. In addition to the assessment of eye movements, participants were asked to rate the aesthetic appeal and the asymmetry of the breasts on a 5-point Likert scale.

Results: Overall, the data showed that participants' rating of the breasts' aesthetic appeal was inversely related to the level of asymmetry. The mean [standard deviation] time until fixation was shortest for the image depicting the greatest breast asymmetry (50 cc) at 0.77 [0.7] seconds (P < 0.001). In addition, the mammary region was also viewed longest in this image at 3.76 [0.5] seconds (P < 0.001). A volume difference of 35 cc between breasts deflected the observers' gaze significantly toward the larger of the asymmetric breasts (P < 0.001).

Conclusions: Surgeons should focus on achieving symmetric breast volume (ie, differences <35 cc between breasts) to avoid noticeable asymmetry with regard to breast size.
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http://dx.doi.org/10.1093/asj/sjab285DOI Listing
October 2021

Using Black Bone Magnetic Resonance Imaging for Fibula Free Flap Surgical Planning: A Means to Reduce Radiation Exposure with Accurate Surgical Outcomes.

Plast Reconstr Surg 2021 Jul;148(1):77e-82e

From the Division of Plastic Surgery and the Department of Radiology, Mayo Clinic.

Summary: Advances in virtual surgical planning and three-dimensionally-printed guides have enabled increased precision in vascularized free fibula flap reconstruction of the mandible and valuable preoperative planning. However, virtual surgical planning currently requires high-resolution computed tomographic scans, exposing patients to ionizing radiation. The aim of this study was to determine whether black bone magnetic resonance imaging can be used for accurate surgical planning and three-dimensionally-printed guide creation, thus reducing patient radiation exposure. This study included 10 cadaver heads and 10 cadaver lower extremities. A mock fibula free flap for mandible reconstruction was performed. Five operations were planned with guides created using black bone magnetic resonance imaging, whereas the other five were planned and performed using guides created with computed tomographic scan data. All specimens underwent a postoperative computed tomographic scan, and three-dimensional reconstruction of scans was performed and surgical accuracy to the planned surgery was assessed. Guides created from black bone magnetic resonance imaging demonstrated high accuracy to the surgical plan. There was no statistically significant difference in postoperative deviation from the plan when black bone magnetic resonance imaging versus computed tomographic scanning was used for virtual surgical planning and guide creation. Both modalities led to a postoperative positive or negative deviation from the virtual plan within 0.8 mm. This study demonstrates that virtual surgical planning and three-dimensionally-printed guide creation for free fibula flaps for mandible reconstruction can be performed using black bone magnetic resonance imaging with comparable accuracy to computed tomographic scanning. This could reduce radiation exposure for patients and enable a more streamlined imaging process for head and neck cancer patients.
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http://dx.doi.org/10.1097/PRS.0000000000008090DOI Listing
July 2021

A 28-year single institution experience with primary skin malignancies in the pediatric population.

J Plast Surg Hand Surg 2022 Feb 25;56(1):53-57. Epub 2021 May 25.

Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.

The aim of this study is to report our institution's experience with pediatric skin malignancies. A single institution retrospective review of pediatric patients with a primary skin malignancy from 1992 to 2020 was performed. Demographics, tumor characteristics and treatment outcomes were reviewed. Ninety-nine patients with 109 primary malignant skin lesions were reviewed. The most common lesion was malignant melanoma [MM] ( = 50, 45.9%). Compared to non-melanoma skin cancer (NMSC), MM were more likely to present on trunk or extremities (=.01, OR = 3.2), and be misdiagnosed (=.03, OR = 2.7). NMSC were more common in the head and neck region (=.01, OR = 3.2), and were associated with a personal history of skin cancer (=.0005, OR = 17.1) or a known risk factor (=.04, OR = 2.5). Patients with MM were 12.4-times more likely to develop metastatic disease compared to NMSC (<.0001). Increased Breslow's thickness also increased the odds of developing metastatic disease (=.03, OR = 1.6 per 1-mm increase). Interval time between lesion recognition and diagnostic biopsy or surgical treatment did not impact overall survival. Malignant melanoma was the most common malignancy in our cohort, followed by basal cell carcinoma. Malignant melanoma was the most likely tumor to be misdiagnosed and/or metastasize. Treatment delays did not impact risk of metastasis, recurrence or survival rate, though some patients succumbed to disease. These results may be attributed to small sample size or the biology of melanoma in pediatric patients. Awareness of skin malignancies in the pediatric population is imperative to providers and the public, with low threshold for specialty consultation and excision when warranted.
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http://dx.doi.org/10.1080/2000656X.2021.1914639DOI Listing
February 2022

Liposuction and Patient Safety: Appropriately Credentialing Providers.

Plast Reconstr Surg 2021 Jun;147(6):1087e-1088e

Division of Plastic and Reconstructive Surgery Department of Surgery Mayo Clinic Phoenix, Ariz.

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http://dx.doi.org/10.1097/PRS.0000000000007970DOI Listing
June 2021

Understanding Facial Muscle Aging: A Surface Electromyography Study.

Aesthet Surg J 2021 08;41(9):NP1208-NP1217

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood.

Objectives: The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers.

Methods: The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles.

Results: The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity).

Conclusions: The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.
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http://dx.doi.org/10.1093/asj/sjab202DOI Listing
August 2021

Signal-To-Noise Ratio Calculations to Validate Sensor Positioning for Facial Muscle Assessment Using Noninvasive Facial Electromyography.

Facial Plast Surg 2021 Oct 5;37(5):614-624. Epub 2021 Mar 5.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.

The evaluation of neuromodulator treatment outcomes can be performed by noninvasive surface-derived facial electromyography (fEMG) which can detect cumulative muscle fiber activity deep to the skin. The objective of the present study is to identify the most reliable facial locations where the motor unit action potentials (MUAPs) of various facial muscles can be quantified during fEMG measurements. The study population consisted of five males and seven females (31.0 [12.9] years, body mass index of 22.15 [1.6] kg/m). Facial muscle activity was assessed in several facial regions in each patient for their respective muscle activity utilizing noninvasive surface-derived fEMG. Variables of interest were the average root mean square of three performed muscle contractions (= signal) (µV), mean root mean square between those contraction with the face in a relaxed facial expression (= baseline noise) (µV), and the signal to noise ratio (SNR). A total of 1,709 processed fEMG signals revealed one specific reliable location in each investigated region based on each muscle's anatomy, on the highest value of the SNR, on the lowest value for the baseline noise, and on the practicability to position the sensor while performing a facial expression. The results of this exploratory study may help guiding future researchers and practitioners in designing study protocols and measuring individual facial MUAP when utilizing fEMG. The locations presented herein were selected based on the measured parameters (SNR, signal, baseline noise) and on the practicability and reproducibility of sensor placement.
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http://dx.doi.org/10.1055/s-0041-1725168DOI Listing
October 2021

Remembering Ian T. Jackson at the Mayo Clinic.

J Craniofac Surg 2021 May;32(Suppl 3):1251-1255

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1097/SCS.0000000000007521DOI Listing
May 2021

Telemedicine in International Cleft Care: A Systematic Review.

Cleft Palate Craniofac J 2021 12 4;58(12):1547-1555. Epub 2021 Feb 4.

12267Wayne State University School of Medicine, Detroit, MI, USA.

Background: Cleft lip and cleft palate (CLP) are among the world's most common congenital malformation and has a higher prevalence in developing nations due to environmental and genetic factors. Global efforts have been developed in order to prevent and treat the malformation. Telemedicine has been implemented in various humanitarian global missions with success and is currently the primary means of care due to COVID-19.

Objective: To assess the benefits and barriers of telehealth in the care of patients with CLP through a global approach.

Methods: Systematic review of the PubMed and Cochrane Review databases with relevant terms related to telemedicine in cleft lip and palate surgery.

Results: Eight articles fit the inclusion criteria and suggested benefits with the use of telemedicine in regard to education, preoperative, and postoperative care as well as increased access to underserved populations. Barriers included connectivity and accessibility concerns.

Conclusion: Telehealth is a beneficial way to evaluate patients with CLP in developing countries with proper care and follow-up to reduce complications and to improve health outcomes.
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http://dx.doi.org/10.1177/1055665621989140DOI Listing
December 2021

Reply: Fat Graft Enrichment Strategies: A Systematic Review.

Plast Reconstr Surg 2020 12;146(6):833e-834e

Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.

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http://dx.doi.org/10.1097/PRS.0000000000007411DOI Listing
December 2020

Impact of COVID-19 on a plastic surgery residency education program: Outcomes of a survey.

J Plast Reconstr Aesthet Surg 2021 03 1;74(3):644-710. Epub 2020 Nov 1.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA. Electronic address:

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http://dx.doi.org/10.1016/j.bjps.2020.10.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604070PMC
March 2021

Using Artificial Intelligence to Measure Facial Expression following Facial Reanimation Surgery.

Plast Reconstr Surg 2020 11;146(5):1147-1150

From the Division of Plastic Surgery, Department of Surgery, Mayo Clinic; the Division of Plastic Surgery, Department of Surgery, Sidra Medicine; and the Department of Surgery, Weill-Cornell Medical College-Qatar.

Social interactions are largely dependent on the interpretation of information conveyed through facial expressions. Although facial reanimation seeks restoration of the facial expression of emotion, outcome measures have not addressed this directly. This study evaluates the use of a machine learning technology to directly measure facial expression before and after facial reanimation surgery. Fifteen study subjects with facial palsy were evaluated both before and after undergoing cross-facial nerve grafting and free gracilis muscle transfer. Eight healthy volunteers were assessed for control comparison. Video footage of subjects with their face in repose and with a posed, closed-lip smile was obtained. The video data were then analyzed using the Noldus FaceReader software application to measure the relative proportions of seven cardinal facial expressions detected within each clip. The facial expression recognition application detected a far greater happy signal in postoperative (42 percent) versus preoperative (13 percent) smile videos (p < 0.0001), compared to 53 percent in videos of control faces smiling. This increase in postoperative happy signal was achieved in exchange for a reduction in the sad signal (15 percent to 9 percent; p = 0.092) and the neutral signal (57 percent to 37 percent; p = 0.0012). For video clips of patients in repose, no significant difference in happy emotion was detected between preoperative (3.1 percent) and postoperative (1.4 percent) states (p = 0.5). This study provides the first proof of concept for the use of a machine learning software application to objectively quantify facial expression before and after surgical reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000007251DOI Listing
November 2020
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