NEW YORK (Reuters Health) – Dynamic facial reanimation surgery benefits patients over age 60 who have facial palsy and should not be denied to them solely because of their age, a new case series suggests.
“Treatment of facial paralysis in the older population is often relegated to static rather than dynamic reanimation for fear of poor outcomes,” the authors write in Plastic and Reconstructive Surgery, online January 16.
“This study,” they say, “refutes this pervasive viewpoint and demonstrates evidence of success for one-stage dynamic reanimation including muscle advancements, free functional muscle transfers, or nerve transfers.”
“Age alone should not preclude patients from getting help. These surgeries are complex and intricate, but they are also very safe, and most importantly, they have a tremendous effect on patients’ lives,” senior author Dr. Shai M. Rozen of the University of Texas Southwestern Medical Center, in Dallas, told Reuters Health by email.
“Hopefully, the results of this study will improve awareness among clinicians and significantly improve the lives of patients who develop facial palsy. Clinicians should refer their patients with facial palsy to surgeons who perform this work regularly in specialized centers and dedicate their careers to improving care for this group of patients,” he advised.
Dr. Rozen and colleagues reviewed outcomes in 30 patients over age 60 treated at three facial palsy centers between 1997 and 2015. Twelve of the patients underwent lengthening temporalis myoplasty (LTM), 14 received free functional muscle transfer (FFMT) innervated by the masseter nerve, and four were treated by direct nerve transfer.
The three groups in the clinical series were similar in average age, preoperative House-Brackman score, and comorbidities. The highest average excursion was reported in the FFMT group (10.4 mm), followed by the nerve transfer (6.8 mm) and temporalis myoplasty (3.1 mm) groups.
The largest average philtral deviation correction occurred in the LTM group (5.6 mm), followed by the FFMT (2.2 mm) and nerve transfer (1.13 mm) groups. The FFMT group had the highest complication rate.
The researchers also surveyed reports from 1968 to 2013 on reanimation in patients over age 60. Out of 629 articles, 57 mentioned an age range over 60, but only 45 patients were reported, with limited detail, providing, according to Dr. Rozen’s team, only “weak evidence supporting (the) misguided concept” that dynamic reanimation should be reserved for younger patients.
“As in many things in the history of surgery, the patients teach us a lot,” Dr. Rozen told Reuters Health. “The truly surprising thing is that many of these patients are told by experienced practitioners, not only primary care physicians but also subspecialists – ear, nose, and throat, neurology, and many others – that there is no solution to their problem and that they should accept it. The main problem I see is lack of awareness.”
Dr. Reid V. Mueller, an associate professor of plastic surgery at Oregon Health and Science University in Portland, told Reuters Health by email that he was not surprised that the older patients in the study responded well to the standard treatments for facial paralysis.
“While there is some evidence that nerves may regenerate more slowly in older patients, that does not in any way take away from the final success of the treatment,” explained Dr. Mueller, who was not involved in the study.
“Age bias is a common phenomenon in medicine,” he said. “All too frequently, older patients are either not offered specific treatments or surgeons subconsciously guide their older patients towards procedures that they feel are more suited to their age. Often there are little or no data to support such decisions.”
“The restoration of facial symmetry in repose and with spontaneous facial animation gives our patients self-confidence, improved self-image, and allows them to use facial expressions for the emotional nuance in verbal and non-verbal communications that are so important to our daily lives in society,” he said. “This study shows that older patients can reliably obtain these goals.”
“These results will help surgeons combat their own subconscious bias about offering these procedures to older adults,” Dr. Mueller added.
“As noted in the article,” he added, “the sooner patients begin their treatment, the better their outcomes. Clinicians should consider referral to a center that can offer a variety of facial reanimation procedures as soon as feasible, regardless of the age of their patient.”
SOURCE: http://bit.ly/2FxMJYw
Plast Reconstr Surg 2018.
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