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One approach to reanimating both upper and lower lips following facial palsy is through staged surgery: cross-face nerve grafting at stage I, free gracilis muscle transfer to levators at stage II and pedicled anterior belly of digastric muscle transfer (ABDMT) to depressors at stage III. The results of this approach were hitherto unquantified.This study retrospectively assessed peer-reviewed, patient-rated and objective outcomes following staged reanimation in adults between 2010 and 2020. Demographics, palsy characteristics and surgery details were recorded. Pre- and postoperative videos were rated by independent assessors using Terzis' aesthetic and symmetry scale. Photographs were analysed using Emotrics and patients completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.Ten patients [mean age = 34 (SD = 12.48)] were eligible. All regained lip elevation and depression. All markers of symmetry improved after gracilis transfer. All markers were also improved after ABDMT except for lower lip height when smiling with teeth showing (p 0.05). Five patients (50%) responded to the GBI (mean score = +39.44). No patients reported detriment from the reanimations. Mean Terzis' scores preoperatively and after stages II and III were 1.5, 2.26 and 2.39, respectively (p 0.05). Nine patients underwent aesthetic refinements [lipofilling to lower lip notches (n = 5), debulking of gracilis bulk (n = 6), repositioning of muscle insertion (n = 5) and facelifts (n = 2)].The outcomes were positive objectively and as judged by peers and patients themselves. Aesthetic refinements may also be required to enhance these results.

The authors previously published positive peer-reviewed (21 raters using the Terzis scale) and photogrammetric (Emotrics) outcomes in patients who had undergone two-stage lower lip reanimations up to 2018. Other series have published surgeon and peer-rated results, but we know of only two (n=12) that have assessed patients' views using patient satisfaction surveys. This paper presents patient-rated outcomes (PROMS) in an 11-year series of both single and two-stage anterior belly of digastric muscle (ABDM) lower lip reanimations. Demographics, paralysis characteristics, operative details, and complications were recorded. Patients were telephoned and requested to complete the Glasgow Benefit Inventory (GBI) to assess patient-rated outcomes. Thirty-two patients were eligible (mean age 36.4 years). Twenty-one (63.6%) completed the GBI (mean score +33.3). More patients reported benefit than detriment (95.2% vs 4.8%). Complications were infrequent and included three cases of superficial infections and one of dermatitis. Four patients (12.5%) underwent minor revisions, mostly lipofilling of lip notches. The median (range) duration of follow up was 2.8 (0.3 - 8.5) years. ABDM transfer for lower lip reanimation is a safe, low morbidity procedure that enhances the psychological wellbeing of patients with facial palsy.

Objective: Oral dissolution therapy is a recognised treatment option for radiolucent kidney stones. A standardised nurse-led protocol was developed. Efficacy and compliance was audited and results reviewed. Methods: Twenty-two patients with radiolucent stones were prescribed oral sodium bicarbonate. Patients monitored their urinary pH and the Urology Nurse Practitioner checked compliance. Follow-up with non-contrast computerised tomography of the kidneys, ureters and bladder (CT KUB) was evaluated at 6 weeks. Results: Twenty patients with radiolucent stones completed treatment. Mean stone size was 8 mm (2–23 mm). Nine patients (45%) had complete dissolution, three (15%) had partial dissolution and eight (40%) had no visible response on follow-up CT KUB. The Hounsfield unit (HU) average was 464 (116–1285). Those patients with complete dissolution had HU of less than 605. Three patients with encrusted ureteric stents underwent complete dissolution. Conclusions: Utilisation of a nurse-led sodium bicarbonate dissolution therapy protocol for the treatment of radiolucent stones is effective and acceptable to patients in carefully selected cases. Orally dissolution therapy (ODT) is a suitable option in patients with multiple co-morbidities and high anaesthetic risk. In our series, ODT was also highly effective in treating radiolucent stent encrustation.

Summary Background This study describes a different approach with a 2-stage facial reanimation in patients with long-standing unilateral facial paralysis using free gracilis muscle transfer, innervated by both cross-facial nerve graft and masseteric nerve. The authors present their rationale, surgical technique, and long-term outcomes. Methods Between August 2012 and March 2016, 11 patients (6 female and 5 male patients) underwent a 2-staged dually innervated gracilis muscle transfer. Patients were evaluated with physical examination and needle electromyography. A standardized assessment of preoperative and postoperative photographs and videos was performed using Terzis’ smile functional grading system at 48 months following surgery and the Emotrics software to assess improvement in symmetry over a 36-month postoperative period. Results Voluntary contraction of the gracilis muscle was observed in all patients at a mean of 4 months and 4 days following muscle transfer. A spontaneous smile produced without teeth clenching was developed in all patients by 18 months postoperatively. Six patients achieved excellent and 5 good results. The difference between the averaged pre- and postoperative scores was statistically significant. With Emotrics, there were significant improvements in the smile angle, upper lip elevation, commissural excursion, and commissural height, with continuous improvement over 36 months. The postoperative electromyography (EMG) confirmed dual innervation of the gracilis muscle by the facial and masseteric donor motor neural sources. We present our results at minimum 48 months postoperatively. Conclusions Dual innervated two-stage gracilis transfer is an effective method for reanimation in long-standing unilateral facial paralysis, providing both rapid reinnervation of the transferred muscle, together with a powerful, synchronous smile.

Summary Introduction This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. Method A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). Results Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). Conclusion We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

Flaps based on the superficial branch of the radial artery (SUPBRA) are indicated when homo- or heterodigital flaps are inappropriate, but glabrous or like-for-like reconstruction is required.To systematically review the outcomes of hand reconstruction using SUPBRA flaps.PubMed was searched for English-language articles studying SUPBRA flaps in November 2019. Data collected included flap vascular supply, dimensions, complications, donor site closure, and two-point discrimination.Twenty-six papers were eligible (410 flaps). Flaps were classified as glabrous, nonglabrous or combined. Nonglabrous flaps were either free- (52%) or reverse-flow pedicled (1.7%) wrist flaps. Glabrous flaps were either free palmar (36.3%), reverse-flow pedicled palmar (2%), antegrade-flow pedicled palmar (0.2%) or perforator-based island palmar flaps (3.7%). Combined glabrous/nonglabrous flaps formed 4.1% of flaps. Maximal flap dimensions allowing direct closure were: 3.1 × 6 cm for wrist flaps and3 × 10 cm for glabrous palmar flaps. Combined flaps can be 10 × 16 cm. Overall, complete and partial flap failure rates were 3.17% and 0.98%, respectively. Most complete failures were due to venous thrombosis. All 220 wrist donor sites were closed directly. Two out of 173 palmar donor sites (≥3.1) could not be primarily closed. Wound complications were rare, but 53.4% of free palmar flaps required debulking. The results of neurorrhaphy were inconsistent.Flaps based on the SUPBRA are robust, provide like-for-like reconstruction of glabrous skin defects in one-stage, offer versatility due to diverse skin paddle orientation patterns and are in the same operative field as the defect.

Fracture-dislocation and pilon injuries of the proximal interphalangeal joints (PIPJ) continue to pose significant management challenges. Stable fracture configurations can be treated with extension block splinting or pinning. Unstable fractures usually require open or closed reduction and fixation either directly/internally onto the fracture using Kirschner wires, cerclage wires, screws or miniplates or indirectly/externally by ligamentotaxis using external fixators which can be dynamic or static. Dynamic external fixators, such as Suzuki’s pins and rubber traction system, S-Quattro and Hynes/Giddins frame, appear intuitive as they provide axial distraction, which reduces the fracture whilst obviating the need to open the fracture. They also allow immediate active movement whilst maintaining reduction. The Ligamentotaxor® (Arex, Pallaiseau Cedex, France) is a commercially-available dynamic external fixator which has been used at our institution since 2013. This retrospective study assessed the outcomes (interphalangeal joint active range of movement (AROM), QuickDASH score and complications) in 19 patients [mean age of 48.6 (SD 16.2)] whose proximal interphalangeal joint (PIPJ) fracture-dislocations and/or pilon fractures were treated with the Ligamentotaxor®. Injuries were classified according to Seno i.e. (1) volar lip fracture ± dorsal dislocation (2) dorsal lip fracture ± volar dislocation (3) pilon fracture. There were fifteen (79%) pilon/Seno 3, three (16%) Seno 1 and one (5%) Seno 2 fractures. The mean PIPJ AROM was 70.6° (SD 4.48°) for all Seno classes and 70° (SD 5.6°) for the pilon subgroup. The QuickDASH score averaged to 2.65 (SD 0.88). There were two pin-site infections, three pin-site inflammations, one osteomyelitis and two complex regional pain syndrome diagnoses. One patient required arthroplasty after missing several appointments. These results, considering the predominance of pilon fractures, compare favourably the published Ligamentotaxor® and other dynamic external fixator systems.

Mini-temporalis transposition (MTT) flaps, modified from Gillies' technique, have become less popular than temporalis tendon transfers for midface reanimation. MTT involves raising the middle third of the temporalis, transposition over the zygomatic arch and lengthening with deep temporalis fascia which is sutured to the orbicularis oris.This retrospective study assessed subjective and objective outcomes following MTTs by a single surgeon from 2009 to 2019.Operative and surgical details were recorded. Four blinded consultants rated pre- and postoperative videos according to Terzis' scale. Pre- and postoperative resting, Mona Lisa and canine smile photographs were analysed using Emotrics, the software that automatically computes differences in inter-landmark distances. Patients also completed the Glasgow Benefit Inventory (GBI) patient-rated outcome measure.Forty-one patients (mean age 65.8 ± 15.5) underwent MTT, median 3 (0.4-57) years post-paralysis and were followed up for median of 2.2 (0.4-8.8) years. Higher mean postoperative Terzis score demonstrates symmetric and aesthetic improvements (3 ± 1.3 vs. 2 ± 1; p0.05). Emotrics analysis showed postoperative improvements in resting and dynamic symmetry of all indices, with the majority statistically significant (p0.003). The mean GBI was 35.19 with 17 (94.4%) patients reporting improvement, whereas one (5.6%) patient reported detriment after surgery. Two (5.4%) patients suffered complications: one haematoma and one infection. Four patients (9.8%) required revisional flap tightening. No patients requested revisional surgery for temporal hollowing or zygomatic fullness.MTT effectively improves both subjective and objective resting and dynamic midface symmetry in a single stage. These results suggest this technique is a good alternative to temporalis tendon transfer techniques.

Supplemental Digital Content is available in the text., Background: Lower lip depression was historically regarded a neglected area of facial paralysis, but, with refinement of techniques, has gained increasing attention. We present the first detailed description and evaluation of a 2-stage technique, using first cross facial nerve graft and then the anterior belly of digastric muscle (ABDM), innervated by the cross facial nerve graft, to restore dynamic and spontaneous lower lip depression. Methods: Retrospective analysis of 2-stage lower lip reanimations between 2010 and 2018 was performed. Demographics, etiology, and operative details were recorded. Videos were graded pre/postoperatively using a 5-point Likert scale by 21 independent observers. Objective changes of symmetry were analyzed using Photogrammetry (Emotrics). Results: Twenty-seven patients were identified (median age 34.9 years, range 6–64). The mean duration between the 2 stages was 15.1 months. Follow-up ranged from 18–72 months. There were minor complications in 4 patients, and 1 case was abandoned due to insufficient length of anterior belly of digastric muscle. Average peer-reviewed scores improved from 2.1 to 3.2 (P < 0.05). Emotrics did not show improvement in static symmetry (P > 0.05). However, during open-lip smiling, lower lip height improved significantly (P < 0.05) whilst dental show improvements approached significance (P < 0.08). Lower lip symmetry was also improved during lower lip depression, as shown by improvements in lower lip height (P < 0.05), smile angle, and dental show (both P < 0.05). Conclusions: These results show the safety and efficacy of 2-stage lower lip reanimation using anterior belly of digastric muscle transposition. This procedure is our choice for longstanding lower lip paralysis and provides coordinated spontaneous lower lip depression, thus enhancing the overall perioral animation and smile.