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Summary Background Botulinum toxin (BT-A) chemodenervation has been proved to significantly improve the physical and psychological well-being of patients suffering from facial synkinesis. Despite this, a cohort of patients has persistent tightness and discomfort around the angle of the jaw, which may be caused by synkinesis within the posterior belly of digastric (PBD) muscle. This study was designed to evaluate the benefits of ultrasound-guided BT-A injections into the PBD. Methods Thirty-three patients with recalcitrant tightness and discomfort around the angle of the jaw, despite maximal facial therapy and platysmal chemodenervation were selected for inclusion. Patients underwent ultrasound-guided BT-A injection into the ipsilateral PBD muscle (skin puncture site 1 cm inferior and posterior to the angle of mandible). Outcomes consisted of the Facial Disability Index (FDI), Synkinesis Assessment Questionnaire (SAQ), and a visual analogue scale (VAS) designed to assess tightness and pain around the PBD when moving the jaw, swallowing, and masticating. Questionnaires were completed two weeks before and postinjection. Statistical analysis was performed using a paired t-test. Results Nineteen patients completed the post-treatment outcome questionnaire. A statistically significant improvement was noted in the physical and social function aspects of the FDI and all aspects of the patient-reported VAS scores apart from tightness and pain on jaw retrusion and swallowing. There was no significant difference in the SAQ. Conclusion This study has demonstrated the patient-perceived benefit of ultrasound-targeted BT-A chemodenervation of PBD. This represents a low-risk treatment option that can be easily added to the repertoire of treatments offered to patients with post paralysis facial synkinesis.

Summary Introduction Lower motor neurone facial paralysis (LMNFP) is often viewed by the general public and wider non-facial palsy fraternity as a cosmetic issue rather than a functional one. In this article, we sought to determine the severity and frequency of oro-motor dysfunction in LMNFP and assess the benefits of physical therapy and rehabilitation in this cohort. Patients and methods A prospective study at our institute was conducted for a one-year period (2015–2016), involving adult patients with LMNFP with significant oro-motor dysfunction. The exclusion criteria were (i) pre-existing oro-motor dysfunction, (ii) within six months of facial palsy onset. The assessment tools used were (i) The Facial Disability Index (FDI), (ii) IPREDD or Inventory of Patient-Reported Eating and Drinking Dysfunction for mastication and (iii) a bespoked Visual Analogue Scale (VAS) based on focus group discussions. Results Of the 183 new clinic referrals, FDI identified that 14% of patients with LMNFP had significant oro-motor dysfunction. IPREDD analysis showed that 74% of this cohort had masticatory problems, while the VAS indicated significant oro-motor dysfunction as well in those with LMNFP. Following speech and facial therapy, IPREDD-focused symptoms were reduced from 74% to 43% (shown to be significant), while VAS similarly showed a significant reduction in symptoms (two-tailed, paired Student's t-test p Discussion Oro-motor function is a significant sequel of facial paralysis. Facial rehabilitation, both physical and psychological, can help reduce patients’ distress and improve oro-motor function, without the need for surgical intervention in the first instance.

Summary Introduction Clinical coding is often a mystery to us surgeons, but in actuality, it has a huge bearing on the financial sustainability of our services. Given the rapid innovations in plastic surgical procedures, clinical coders often struggle to decipher the extent of surgery. Meeting midway is the way forward here. Methods In a prospective audit over a six-month period, we analysed data from 2586 patients in our practice: a combination of general plastic surgery and specialist facial reanimation services. This involved comparing data from the first three months where coding was performed by clinical coders based on operating notes per se (phase I) and the subsequent three months when the operating surgeon filled in the OPCS 4.7 (version 2014) codes at the time of completing the operating notes; the clinical coders then vetted this information (phase II) as part of a sequential TBS coding system. Results In terms of outpatient income, there was a 3% increase in facial palsy income and 6% increase in general plastic services, but the most significant improvement was in terms of procedural income per case. General plastic surgery cases saw an increase of 49%, while facial palsy income increased by 58% over the same period. Greater insight into OPCS and HRG codes also allowed for the calculation of the actual tariffs for specific procedures. Conclusions Having the operating surgeon as the primary coder, using a template, with subsequent vetting by the clinical coders, improves data capture, and this in turn increases income. Future recommendations include the use of proforma-based operating notes for workhorse procedures.