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IMPORTANCE:. Pediatric acute kidney injury (AKI) is a prevalent and morbid complication of shock. Its pathogenesis and early identification remain elusive. OBJECTIVES:. We aim to determine whether renal blood flow (RBF) measurements by point-of-care ultrasound (POCUS) and renin-angiotensin-aldosterone system (RAAS) hormones in pediatric shock associate with vasoactive requirements and AKI. DESIGN, SETTING, AND PARTICIPANTS:. This is a single-center prospective, noninterventional observational cohort study in one tertiary PICU in North American from 2020 to 2022 that enrolled children younger than 18 years with shock without preexisting end-stage renal disease. MAIN OUTCOMES AND MEASURES:. RBF was measured by POCUS on hospital days 1 and 3 and plasma RAAS hormone levels were measured on day 1. The primary outcome was the presence of AKI by Kidney Disease Improving Global Outcomes criteria at first ultrasound with key secondary outcomes of creatinine, blood urea nitrogen (BUN), Vasoactive-Inotrope Score (VIS), and norepinephrine equivalent dosing (NED) 48 hours after first ultrasound. RESULTS:. Fifty patients were recruited (20 with AKI, mean age 10.5 yr, 48% female). POCUS RBF showed lower qualitative blood flow (power Doppler ultrasound [PDU] score) and higher regional vascular resistance (renal resistive index [RRI]) in children with AKI (p = 0.017 and p = 0.0007). Renin and aldosterone levels were higher in the AKI cohort (p = 0.003 and p = 0.007). Admission RRI and PDU associated with higher day 3 VIS and NED after adjusting for age, day 1 VIS, and RAAS hormones. Admission renin associated with higher day 3 creatinine and BUN after adjusting for age, day 1 VIS, and the ultrasound parameters. CONCLUSIONS AND RELEVANCE:. In pediatric shock, kidney blood flow was abnormal and renin and aldosterone were elevated in those with AKI. Kidney blood flow abnormalities are independently associated with future cardiovascular dysfunction; renin elevations are independently associated with future kidney dysfunction. Kidney blood flow by POCUS may identify children who will have persistent as opposed to resolving AKI. RAAS perturbations may drive AKI in pediatric shock.

Summary:. The forehead flap is a timeless and robust reconstructive option for complex facial defects. In accordance with aesthetic subunit principles, it has traditionally been used to resurface defects affecting a single cervicofacial region, most commonly the nose or periorbital unit. In this article, we present three cases of congenital nevi treated with expanded forehead flap reconstruction of the nasal, periorbital, and cheek units in early childhood. This series demonstrates an approach that, while violating facial units, limits total scar burden and optimizes aesthetic and functional results. With precise staging and execution, this reconstructive technique allows for a single flap to resurface multi-unit defects in the pediatric population with excellent long-term results.

OBJECTIVES:. To determine the predictive value of social determinants of health (SDoH) variables on 30-day readmission following a sepsis hospitalization as compared with traditional clinical variables. DESIGN:. Multicenter retrospective cohort study using patient-level data, including demographic, clinical, and survey data. SETTINGS:. Thirty-five hospitals across the United States from 2017 to 2021. PATIENTS:. Two hundred seventy-one thousand four hundred twenty-eight individuals in the AllofUs initiative, of which 8909 had an index sepsis hospitalization. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Unplanned 30-day readmission to the hospital. Multinomial logistic regression models were constructed to account for survival in determination of variables associate with 30-day readmission and are presented as adjusted odds rations (aORs). Of the 8909 sepsis patients in our cohort, 21% had an unplanned hospital readmission within 30 days. Median age (interquartile range) was 54 years (41–65 yr), 4762 (53.4%) were female, and there were self-reported 1612 (18.09%) Black, 2271 (25.49%) Hispanic, and 4642 (52.1%) White individuals. In multinomial logistic regression models accounting for survival, we identified that change to nonphysician provider type due to economic reasons (aOR, 2.55 [2.35–2.74]), delay of receiving medical care due to lack of transportation (aOR, 1.68 [1.62–1.74]), and inability to afford flow-up care (aOR, 1.59 [1.52–1.66]) were strongly and independently associated with a 30-day readmission when adjusting for survival. Patients who lived in a ZIP code with a high percentage of patients in poverty and without health insurance were also more likely to be readmitted within 30 days (aOR, 1.26 [1.22–1.29] and aOR, 1.28 [1.26–1.29], respectively). Finally, we found that having a primary care provider and health insurance were associated with low odds of an unplanned 30-day readmission. CONCLUSIONS:. In this multicenter retrospective cohort, several SDoH variables were strongly associated with unplanned 30-day readmission. Models predicting readmission following sepsis hospitalization may benefit from the addition of SDoH factors to traditional clinical variables.

Background:. Nipple-sparing mastectomy (NSM) preserves the natural nipple–areola complex and entire native breast skin, with the goal of better cosmetic outcomes in breast reconstruction. In bilateral TE/implant-based reconstruction requiring unilateral postmastectomy radiotherapy (PMRT), progressive radiation-induced fibrosis can lead to increasing nipple asymmetry with cosmetic dissatisfaction. Thus, PMRT may ultimately negate the intended positive cosmetic value of NSM compared with skin-sparing mastectomy (SSM). This study compares (1) surgical complications, (2) patient satisfaction, and (3) aesthetic outcomes between NSM versus SSM in bilateral implant-based reconstruction with unilateral PMRT. Methods:. This retrospective matched cohort study included consecutive NSM patients with bilateral TE/implant breast reconstruction + unilateral PMRT matched 1:2 to SSM group. Patients completed PMRT and TE exchange to implants. Demographics, oncologic stage, comorbidities, and complications were collected. Patient satisfaction was evaluated by BREAST-Q. Aesthetic outcomes were assessed by blinded reviewers with a five-point Likert scale. Results:. Among 58 patients who underwent bilateral TE/implant reconstruction with unilateral PMRT, 17 NSM patients were matched to 41 SSM patients by age, body mass index, and comorbidities. No significant differences existed in overall surgical complications and individual BREAST-Q questionnaire scores between cohorts. However, aesthetic outcomes scores were higher in SSM compared with NSM. Conclusions:. Although NSM is generally associated with superior cosmetic outcomes compared with SSM, it has far less impact in bilateral implant-based breast reconstruction with unilateral PMRT due to the negative postradiotherapy effect on nipple symmetry.

Summary:. Apert syndrome classically presents with craniosynostosis at birth, most commonly of the bilateral coronal sutures, which may lead to cephalocranial disproportion and elevated intracranial pressure, the latter of which is associated with optic atrophy, visual loss, and developmental delays. A small number of patients with syndromic craniosynostosis demonstrate open sutures at birth; however, all previously reported patients of this subtype have been reported to develop premature suture fusion in the early postnatal period and/or require cranial vault expansion for increased intracranial pressure. Here, we report on a patient with Apert syndrome who did not have closed sutures at birth, and only began to demonstrate unilateral coronal suture fusion between ages 4 and 6 years, yet neither developed phenotypic signs of craniosynostosis nor evidence of intracranial hypertension. Moreover, despite demonstrating patency of the spheno-occipital synchondrosis, the patient developed progressive midface hypoplasia, requiring a subcranial Le Fort 3 advancement with external distraction at age 9. Now at skeletal maturity, this patient has a normal cranial shape and will likely never require cranial vault surgery for functional or aesthetic concerns. We are not aware of any prior reports of a patient with Apert syndrome who did not require intracranial surgery over long-term follow-up.

Background:. Black haircare is an estimated $2.51-billion-dollar industry. Black women spend 9 times more on ethnic hair products than non-Black consumers. The haircare industry has adapted to these market trends by developing products catering to the needs of “natural hair,” referring to curly to tightly coiled hair texture that has not been chemically straightened with a relaxer. Anecdotally, natural haircare products are relatively expensive. Objective:. We aimed to investigate texture-based price differences for haircare products targeting coily/curly compared to straight hair types. Methods:. Data were collected in August 2022 from 6 brands available on www.amazon.com. After stratifying the data by manufacturer, hair texture, and average price/oz, we used 2 sample t-test with equal variances to examine cost differences. Results:. Overall, there was a significant difference in average price/oz between all coily/curly and straight hair products, with coily/curly hair products being more expensive. When stratified by manufacturer, one leading US manufacturer sold coily/curly hair products at a higher price ($0.66/oz ±$0.05) compared with straight hair products ($0.46/oz ±$0.04), t14 = 2.8967, P < 0.0134. Limitations:. A small sample size of only shampoos and conditioners were analyzed, which may not represent the number of haircare products that consumers use. Conclusion:. Pricing policies should ensure that all individuals have access to effective, affordable haircare products. Dermatologists should also be cognizant of pricing differences to direct patients with natural hair to fairly priced products.

IMPORTANCE:. Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes. OBJECTIVES:. The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices. DESIGN, SETTING, AND PARTICIPANTS:. This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning. MAIN OUTCOMES AND MEASURES:. Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams. RESULTS:. Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes. CONCLUSIONS AND RELEVANCE:. Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care.

Background:. Unilateral lambdoid craniosynostosis is differentiated from deformational plagiocephaly primarily by assessing the cranium from posterior and bird’s-eye views. Findings include posterior displacement of the ipsilateral ear, ipsilateral occipitomastoid bossing, ipsilateral occipitoparietal flattening, contralateral parietal bossing, and contralateral frontal bossing. Diagnosis based off facial morphology may be an easier approach because the face is less obstructed by hair and head-coverings, and can easily be assessed when supine. However, frontofacial characteristics of unilateral lambdoid craniosynostosis are not well described. Methods:. A retrospective cohort review of patients with isolated, unilateral lambdoid craniosynostosis from the Children’s Hospital of Pittsburgh and the Children’s Hospital of Philadelphia was performed. Preoperative frontal and profile photographs were reviewed for salient characteristics. Results:. Nineteen patients met inclusion criteria. Eleven patients had left lambdoid craniosynostosis, and eight had right lambdoid craniosynostosis. All patients were nonsyndromic. Patients demonstrated contralateral parietal bossing and greater visibility of the ipsilateral ear. Contralateral frontal bossing was mild. The orbits were tall and turricephaly was present in varying severity. Facial scoliosis as a C-shaped deformity was present in varying severity. The nasal root and chin pointed to the contralateral side. Conclusions:. The combination of greater visibility of the ipsilateral ear, contralateral parietal bossing, and C-shaped convex ipsilateral facial scoliosis are hallmark frontofacial features of unilateral lambdoid craniosynostosis. Although the ipsilateral ear is more posterior, the greater visibility may be attributed to lateral displacement from the mastoid bulge. Evaluation of long-term postoperative results is needed to assess if this pathognomonic facial morphology is corrected following posterior vault reconstruction.

OBJECTIVES:. Screening for cognitive impairment following ICU discharge is recommended but not part of routine care. We sought to understand older adults’ perspectives on screening for cognitive impairment following an ICU admission to inform the design and delivery of a cognitive screening intervention. DESIGN:. Qualitative study using semi-structured interviews. SUBJECTS:. Adults 60 years and older within 3 months of discharge from an ICU in an academic health system. INTERVENTIONS:. Interviews were conducted via telephone, audio recorded and transcribed verbatim. All transcripts were coded in duplicate. Discrepancies were resolved by consensus. Codes were organized into themes and subthemes inductively. MEASUREMENTS AND MAIN RESULTS:. We completed 22 interviews. The mean age of participants was 71 ± 6 years, 14 (63.6%) were men, 16 (72.7%) were White, and 6 (27.3%) were Black. Thematic analysis was organized around four themes: 1) receptivity to screening, 2) communication preferences, 3) information needs, and 4) provider involvement. Most participants were receptive to cognitive screening; this was influenced by trust in their providers and prior experience with cognitive screening and impairment. Participants preferred simple, direct, compassionate communication. They wanted to understand the screening procedure, the rationale for screening, and expectations for recovery. Participants desired input from their primary care provider to have their cognitive screening results placed in the context of their overall health, because they had a trusted relationship, and for convenience. CONCLUSIONS:. Participants demonstrated limited understanding of and exposure to cognitive screening but see it as potentially beneficial following an ICU stay. Providers should use simple, straightforward language and place emphasis on expectations. Resources may be needed to assist primary care providers with capacity to provide cognitive screening and interpret results for ICU survivors. Implementation strategies can include educational materials for clinicians and patients on rationale for screening and recovery expectations.

Summary:. Traumatic dog bites of the face and head are common among the pediatric population, although injuries resulting in total or subtotal scalp avulsions are rare and life-threatening. Standard treatment in these cases includes attempts at replantation or free tissue transfer; however, these procedures may not always be possible. An alternative treatment option involves the use of dermal substitutes, such as Integra (Integra LifeScience Corporation), with subsequent skin grafting. More recently, an alternative skin substitute called NovoSorb Biodegradable Temporizing Matrix (BTM) (PolyNovo North America LLC) has displayed favorable reconstructive outcomes in recent burn literature. NovoSorb BTM is a novel, fully synthetic bilayer scaffold made of biodegradable polyurethane matrix covered with a sealing membrane. In this report, the authors describe a 3-year-old boy who presented emergently with a severe dog bite avulsion to the subpericranial level of approximately 80% of his scalp, which was not replantable. The surgical plan involved a staged reconstruction using Integra and later skin grafting. Purulent infection ensued and required removal of Integra less than 2 weeks from application. Upon clearing of the infection, the wound was successfully closed with BTM and subsequent skin grafting. With proper wound management and over 6 months of follow-up, the patient experienced excellent healing of the graft with stable calvarial coverage and an acceptable aesthetic outcome. He will undergo tissue expansion of the remaining hair-bearing scalp in the future.

Background:. Computer-aided surgical planning has become popular for planning orthognathic surgery (OS) as it saves surgeons’ time and effort. A recent advancement has been the utilization of patient-specific cutting guides and osteosynthesis. The purpose of this study is to report the postoperative bimaxillary position utilizing custom plates for both jaws versus custom plates used in the maxilla only in 23 consecutive patients. Methods:. All patients who underwent bimaxillary OS in 2017–2018 with preoperative computed tomography (CT) scan, postoperative day 1 CT scan, and at least 6 months follow-up were included in the study. Group 1 utilized maxillary preprinted plates (maxilla only). Group 2 utilized bimaxillary preprinted plates (maxillomandibular). Eight cephalometric landmarks to evaluate the movements were chosen. The ranges of the angle between the sella/nasion plane and the nasion/A plane (SNA), the angle between the sella/nasion plane and the nasion/B plane (SNB), and the angle created by the A point‚ nasion‚ and B point‚ which measures the relative position of maxilla to mandible, were analyzed to assess the angular change. Mean-squared displacement and the SD of the distances were used to assess movement in space. Results:. Twenty-three patients (nine in group 1 and 14 in group 2) met the inclusion criteria. Results showed interarch relationships using custom plates for both jaws with ANB 0.4 compared to ANB 1.4 for maxillary custom plates only. Mandibular landmarks showed greater variation, and the t test study revealed the right mandibular first molar landmark showing the greatest variation (P = 0.03). Conclusions:. Custom osteosynthesis plates for OS show good accuracy for the maxilla and higher variation in the mandible. Further studies will determine the margin of error that cannot be corrected with postoperative orthodontics.

OBJECTIVES:. Survivors of sepsis hospitalization are at high risk for postsepsis morbidity, readmission, and death, but these negative outcomes can be mitigated by receipt of recommended care practices. We sought to assess factors associated with the receipt of recommended recovery-oriented care practices during hospitalization for sepsis. We hypothesized that patients treated in the ICU may be more likely than ward-treated patients to receive recommended care practices given the increasing focus on survivorship in the critical care field. DESIGN:. Observational cohort study. SETTING:. Michigan Medicine, a tertiary academic medical center. PATIENTS:. Adult patients discharged alive from a hospitalization with a primary diagnosis of sepsis or septic shock in 2019. We further limited our cohort to patients receiving longitudinal care viewable in the Michigan Medicine electronic health record to ensure ability to capture posthospital care and outcomes. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Three-hundred sixty-five sepsis hospitalizations met study inclusion criteria. Using structured chart review, we determined receipt of the following recovery-based care practices during hospitalization: medication optimization, functional status evaluation at discharge, sepsis education, and scheduled follow-up within 2 weeks. The cohort was 46.6% female, 81.1% White, with a median age of 64 years. 51.2% were treated in the ICU. Medication optimization occurred in 93.7%, functional status evaluation in 82.7%, sepsis education in 20.0%, and scheduled follow-up within 2 weeks in 54.5%. ICU-treated patients had lower receipt of medication optimization and follow-up scheduling but greater receipt of functional and mental health status evaluations. In multivariable models, ICU treatment was associated with lower odds of receiving medication optimization (adjusted odds ratio, 0.72; 95% CI, 0.03–0.69) and not associated with receipt of other care practices. CONCLUSIONS:. Our study shows incomplete receipt of recommended recovery-based care practices during sepsis hospitalization in both ward and ICU-treated patients. Sepsis education and mental health evaluation were particularly uncommon.

Background:. Plastic and Reconstructive Surgery (PRS) incorporated the level of evidence (LOE) pyramid in 2011 to highlight evidence-based medicine in plastic surgery. This study aimed to assess the relationship between the profile of senior authors publishing in PRS and the LOE of publications. Methods:. All accepted publications by American senior authors to PRS between January 2018 and March 2020 were classified by LOE. Demographic, educational, and career data on all senior authors were collected using publicly available online resources. Results:. A total of 1030 articles were screened‚ of which 266 (25.8%) were eligible for LOE classification with the following distribution: I, 0.8%; II, 14.3%; III, 45.1%; IV, 33.1%; and V, 7.1%. Senior author demographic factors, including gender and race/ethnicity, did not significantly impact LOE (P > 0.05 for all). An advanced degree was associated with more publications per year, and only a PhD (P = 0.022) and board certification (P = 0.012) were associated with a higher LOE of publications (P = 0.022). Physicians working in an academic setting were significantly more likely to publish level III evidence than their private/community-based counterparts (P = 0.006). Breast papers constituted the highest proportion of level III evidence (41.4%; P < 0.001). Conclusions:. Most publications in PRS contain level III-IV evidence. Senior author gender, race, and ethnicity did not impact LOE of publications. Plastic surgery board certification, possession of a PhD, and academic practice setting were associated with higher LOE of publications.

OBJECTIVE:. To summarize knowledge and identify gaps in evidence about the relationship between social determinants of health (SDH) and postsepsis outcomes. DATA SOURCES:. We conducted a comprehensive search of PubMed/Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, and the Cochrane Library. STUDY SELECTION:. We identified articles that evaluated SDH as risk factors for mortality or readmission after sepsis hospitalization. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION:. We dual-extracted study characteristics with specific focus on measurement, reporting, and interpretation of SDH variables. DATA SYNTHESIS:. Of 2,077 articles screened, 103 articles assessed risk factors for postsepsis mortality or readmission. Of these, 28 (27%) included at least one SDH variable. Inclusion of SDH in studies assessing postsepsis adverse outcomes increased over time. The most common SDH evaluated was race/ethnicity (n = 21, 75%), followed by payer type (n = 10, 36%), and income/wealth (n = 9, 32%). Of the studies including race/ethnicity, nine (32%) evaluated no other SDH. Only one study including race/ethnicity discussed the use of this variable as a surrogate for social disadvantage, and none specifically discussed structural racism. None of the studies specifically addressed methods to validate the accuracy of SDH or handling of missing data. Eight (29%) studies included a general statement that missing data were infrequent. Several studies reported independent associations between SDH and outcomes after sepsis discharge; however, these findings were mixed across studies. CONCLUSIONS:. Our review suggests that SDH data are underutilized and of uncertain quality in studies evaluating postsepsis adverse events. Transparent and explicit ontogenesis and data models for SDH data are urgently needed to support research and clinical applications with specific attention to advancing our understanding of the role racism and racial health inequities in postsepsis outcomes.

OBJECTIVES:. To assess the pragmatism of published critical care randomized controlled trials self-described as pragmatic using a validated tool. DATA SOURCES:. Medical Literature Analysis and Retrieval Online database and PubMed interface from inception to November 1, 2021. STUDY SELECTION:. We performed a systematic search of randomized controlled trials evaluating interventions for critically ill adults that self-identified as pragmatic in title or abstract. DATA EXTRACTION:. Reviewers independently performed study selection and data extraction in duplicate; discrepancies were resolved by consensus. Pragmatism was assessed independently in duplicate by trained reviewers using the Pragmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2), a validated tool designed to represent how explanatory/pragmatic a trial is on the pragmatic to explanatory continuum. Trials were scored in nine domains on a 5-point continuum (from 1 = very explanatory to 5 = very pragmatic). Discrepancies of greater than 2 points were adjudicated by consensus discussion. DATA SYNTHESIS:. The search resulted in 284 studies; 56 met eligibility criteria. Forty-one of the trials had a discrepancy in at least one domain that required consensus discussion, most commonly in domains of eligibility and follow-up. Twelve studies (21.4%) were scored as “overall pragmatic,” defined as score of greater than 4 in five domains provided the scores in the remaining domains were three. The overall PRECIS-2 score of self-identified pragmatic studies increased from 1995 to 2021 suggesting increasing pragmatism over time. Pragmatic trials were more likely to have a waiver of informed consent (p = 0.05). CONCLUSIONS:. The number and pragmatism of self-identified pragmatic trials have increased, particularly in the past decade. However, less than one-quarter of these trials that use the term pragmatic in title or abstract were retrospectively rated as pragmatic. Our results support the concept that trials are designed on a spectrum of pragmatic to explanatory. Advances in the design and reporting of critical care trials are needed to ensure their real-world applicability.

Skin lightening (SL) for cosmetic reasons is associated with profound negative impacts on well-being and adverse effects on the skin, resulting in immense challenges for dermatologists. Despite current regulations, lightening agents continue to dominate the cosmetic industry. In this review, our international team of dermatologists tackles the topic of SL as a global public health issue, one of great concern for both women’s health and racial implications. We have examined SL in Africa, Asia, the Middle East, and the Americas. We aim to inspire a global discourse on how modern dermatologists can utilize scientific evidence and cultural competency to serve and protect patients of diverse skin types and backgrounds. In doing so, we hope to promote healthy skin and inclusive concepts of beauty in our patients and society.

Background:. Facial paralysis has profound effects on the functional and psychosocial well-being of patients. Various surgical facial reanimation techniques have been described to address this devastating condition. While traditional surgical approaches have proved successful in restoring either facial tone or facial movement, newer combination nerve transfer techniques are addressing the limitations of the traditional single nerve transfer approaches. Methods:. This study aimed to describe a promising new surgical approach to facial reanimation utilizing a dual nerve transfer to maximize both resting and active symmetry while minimizing postoperative synkinesis. Here, we use the masseteric nerve to selectively innervate the midface in combination with a hypoglossal facial nerve graft to reanimate the remaining facial regions. Results:. To date, we have performed this operation on four patients, all of whom tolerated the procedure well. Our patients are showing significant improvements in both resting facial tone and facial movement with no signs of synkinesis at 9 months postoperative. Conclusions:. We believe this dual nerve transfer to be superior in restoring the combination of tone, symmetry, and movement to the paralyzed face when compared with traditional single nerve transfer approaches.