Selective Surface Electrostimulation of the Denervated Zygomaticus Muscle

Abstract

This article describes a first attempt to generate a standardized and safe selective surface electrostimulation (SES) protocol, including detailed instructions on electrode placement and stimulation parameter choice to obtain a selective stimulation of the denervated zygomaticus muscle (ZYG), without unwanted simultaneous activation of other ipsilateral or contralateral facial muscles.

Methods: Single pulse stimulation with biphasic triangular and rectangular waveforms and pulse widths (PW) of 1000, 500, 250, 100, 50, 25, 15, 10, 5, 2, 1 ms, at increasing amplitudes between 0.1 and 20 mA was performed. Stimulations delivered in trains were assessed at a PW of 50 ms only. The stimulation was considered successful exclusively if it drew the ipsilateral corner of the mouth upwards and outwards, without the simultaneous activation of other ipsilateral or contralateral facial muscles. I/t curves, accommodation quotient, rheobase, and chronaxie were regularly assessed over 1-year follow-up.

Results: 5 facial paralysis patients were assessed. Selective ZYG response in absence of discomfort and unselective contraction of other facial muscle was reproducibly obtained for all the assessed patients. The most effective results with single pulses were observed with PW ≥ 50 ms. The required amplitude was remarkably lower (≤5 mA vs. up to 15 mA) in freshly diagnosed (≤3 months) than in long-term facial paralysis patients (>5 years). Triangular was more effective than rectangular waveform, mostly because of the lower discomfort threshold of the latter. Delivery of trains of stimulation showed similar results to the single pulse setting, though lower amplitudes were necessary to achieve the selective ZYG response. Initial reinnervation signs could be detected effectively by needle-electromyography (n-EMG).

Conclusion: It is possible to define stimulation parameters able to elicit an effective selective stimulation of a specific facial muscle, in our case, of the ZYG, without causing discomfort to the patient and without causing unwanted unspecific reactions of other ipsilateral and/or contralateral facial muscles. We observed that the SES success is strongly conditioned by the correct electrode placement, which ideally should exclusively interest the area of the target muscles and its immediate proximity.

Keywords: electrostimulation; facial palsy; facial paralysis; muscle atrophy; reinnervation; surface electrodes; zygomaticus muscle.

Figure 1

Example of how the electrode placement was conducted during the study (from the patient’s diary specifically generated for the study).

Figure 2

Biphasic single pulse stimulation pattern with a PW of 1000, 500 and 100 ms, delivered with triangular (above) or rectangular waveform (below). ms = milliseconds; mA = milliampere.

Figure 3

Percentage of successful selective ZYG response (y-axis) when the stimulation was presented with specific PWs (x-axis) over 1-year follow-up. ms = milliseconds.

Figure 4

Strength duration curves of all the assessed patients. (A) Amplitude required to observe a selective ZYG response (y-axis) with triangular waveform stimulation, at selected visits (x-axis). (B) Amplitude required to observe a selective ZYG response (y-axis) with rectangular waveform stimulation, at selected visits (x-axis). The colors describe the facial paralysis duration and the form of the plotted outcome the applied PW. ms = milliseconds, mA = milliampere, w = week.

Figure 5

Example of a strength duration curve of patient DFP0101001 at 4 weeks follow up for single pulse stimulation delivered with triangular (blue) or rectangular (red) waveform (data are shown in Figure 6).

Figure 6

Over time changes in the threshold amplitude required to observe a selective ZYG response without unspecific activation of other facial muscles and/or pain/discomfort for evaluated PWs between 1000 ms and 25 ms with stimulations delivered with a triangular ∆ or a rectangular □ waveform.

Figure 7

Percentage of occurrence of discomfort or unselective facial muscle response before reaching an amplitude sufficient to elicit a selective ZYG response (y-axis) when the stimulation was presented with specific PWs (x-axis) over 1-year follow-up upon first stimulation. ms = milliseconds.