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Background: The treatment of postparetic facial synkinesis is based on a combination of nonsurgical and surgical strategies. Improvements toward the restoration of a natural smile have been obtained with selective neurectomies and depressor anguli oris myectomy, but the lower lip frequently remains asymmetric and cranially displaced. The aim of this study was to evaluate the effect of the mentalis muscle on the position and symmetry of the lower lip in patients with synkinesis and to assess the added benefit of neurectomies of nerves innervating the mentalis muscle in improving the lower lip configuration and mandibular teeth show., Methods: A retrospective cohort study of all patients with postparetic synkinesis was performed at the authors' institution. A nonmentalis neurectomy group including 12 patients treated with selective neurectomies without targeting the branches to mentalis muscle was compared with a mentalis neurectomy group including 16 patients who underwent additional specific mentalis branches neurectomies. All patients underwent depressor anguli oris myectomy. Analyses of standardized images were performed with ImageJ software., Results: Postoperative comparisons between the 2 groups showed superior and significant improvements in the mentalis neurectomy group across all measures, including lower and upper border deviation ( P = 0.035 and P = 0.004, respectively), inclination of the lower lip ( P = 0.019), and lower quadrant dental show ( P = 0.004)., Conclusion: The addition of targeted selective neurectomies to the branches innervating the mentalis muscle significantly improved dental show and caudal position and symmetry of the lower lip during open-mouth smile., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background:  Muscles affected by postparetic synkinesis have imbalanced tonicity that limit perioral mimetic movement and inhibit the ability to smile. The depressor anguli oris (DAO) muscle has been a common myectomy target for the treatment of perioral synkinesis. While addition of buccinator myectomies to DAO myectomies has risen, no studies have analyzed the effects of buccinator myectomies. The goal of this study was to evaluate and compare the effects of a DAO myectomy with and without concomitant buccinator myectomy through objective facial metrics and subjective patient-reported outcomes., Methods:  This study is a retrospective review of patients with postparetic synkinesis who underwent DAO myectomy (DAO myectomy group) or DAO myectomy with buccinator myectomy (DAO + Buccinator myectomies group). Outcomes included postoperative differences in objective smile measures (smile angle, excursion, and dental show) using validated software and patient-reported outcomes using the Facial Disability Index (FDI) questionnaire and a myectomy-specific questionnaire., Results:  After chart review, 18 patients were included in the DAO myectomy group and 19 in the DAO + Buccinator myectomies group. There were no significant postoperative differences between the groups in (1) smile excursion, angle, or dental show at resting, closed smile, or open smile ( p  > 0.05), (2) FDI physical and social scores, p  = 0.198 and 0.932, respectively, or (3) myectomy-specific questionnaire responses ( p  > 0.05)., Conclusion:  The addition of a buccinator myectomy to a DAO myectomy does not provide significant clinical benefit when compared with an isolated DAO myectomy, based on objective measures and subjective patient-reported outcomes., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: In postparetic synkinesis, muscle tone imbalance between upper and lower lip depressors and elevators results in the inability to produce an effective smile. Surgical treatments to improve smile focus on restoring tonicity balance between perioral muscles by weakening hypertoned muscles through selective myectomies or selective neurectomies. The goal of this study was to compare objective outcomes between selective myectomies alone with those of selective myectomies combined with selective neurectomies., Methods: A retrospective cohort study was performed on postparetic synkinesis patients who underwent depressor anguli oris (DAO) myectomies or DAO and platysma myectomies with selective neurectomies. Objective outcomes included preoperative and postoperative analyses of smile measures (excursion, angle, and dental show) and botulinum toxin type A administration (periorbital and platysmal)., Results: Thirty-seven patients underwent DAO myectomies only (myectomy group), and 18 patients underwent DAO and platysma myectomies with selective neurectomies (myectomy-neurectomy group). Within-group analyses showed significant angle improvement in both groups ( P < 0.05) and improved smile excursion in the myectomy-neurectomy group ( P < 0.05). Between-group comparisons showed significant closed mouth smile excursion improvement (difference in means, -1.14 mm; 95% CI, -2.19 to -0.09 mm; P = 0.034) and a significant decrease in platysmal botulinum toxin type A administration (difference in means, 27.36 units; 95% CI, 18.72 to 36.00 units; P < 0.001) in the myectomy-neurectomy group compared with the myectomy group., Conclusions: This study suggests that selective myectomies and selective myectomies with selective neurectomies provide overlapping and differing benefits to perioral synkinesis. Selective neurectomies and platysma myectomy provided slightly improved excursion and significantly decreased botulinum injections to the platysma., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Abstract: Facial paralysis can severely impact functionality and mental health. Facial reanimation surgery can improve facial symmetry and movement. Zygomaticus minor (Zmin) and zygomaticus major (Zmaj) are 2 important perioral muscles, that function to elevate the upper lip, contributing to the formation of a smile. The objective of this study was to analyze the morphology in three-dimensional (3D) and quantify architectural parameters of Zmin and Zmaj. In ten formalin-embalmed specimens, Zmin and Zmaj were serially dissected and digitized at the fiber bundle level. The 2 muscles were modeled in 3D to construct high fidelity models. The 3D models were used to assess muscle morphology and quantify architectural parameters including mean fiber bundle length, physiological cross-sectional area, and line of action. Zygomaticus minor fiber bundles were oriented horizontally or slightly obliquely and had a muscular attachment to the medial modiolus. Zygomaticus minor was found to either have no partitions or medial and lateral partitions. Specimens with partitions were divided into type 1 and type 2. Type 1 consisted of a medial partition with fiber bundles attaching to the zygomatic bone at the inferior margin of the orbit. The type 2 medial partition attached to the lateral margin of the orbit to attach to the zygomatic bone. Zygomaticus major had obliquely oriented fiber bundles with most specimens having inferior and superior partitions attaching to the inferior aspect of the zygomatic bone. Zygomaticus major was found to have a greater mean fiber bundle length and physiological cross-sectional area than Zmin. The direction of the line of action of Zmin and Zmaj was closely related to fiber bundle arrangement. Detailed 3D anatomical understanding of Zmin and Zmaj, at the fiber bundle level, is critical for reconstructive surgeons performing dynamic facial reanimation. This data can be used to assist with selecting the ideal donor site for reconstruction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Background: Nonflaccid facial palsy is a debilitating entity characterized by hypertonicity, synkinesis, and hypomobility. Patients with nonflaccid facial palsy often have smile asymmetry and restriction because of disruption of normal vector forces on the modiolus. Excision of the depressor anguli oris can lead to improved oral commissure excursion, smile angle, dental show, and symmetry., Methods: All depressor anguli oris resection cases between January 8, 2018, and December 26, 2019, were reviewed. Patients with postoperative photographs were included in this cohort study. Preoperative and postoperative photographs were analyzed using the Emotrics software program, and changes in oral commissure excursion, smile angle, and dental show were tracked. Clinician-graded facial palsy assessments and patient-reported outcome measures were compared preoperatively and postoperatively using the Electronic Facial Paralysis Assessment and Facial Clinimetric Evaluation Scale, respectively., Results: Forty-three patients were included in this study; 79 percent of patients underwent isolated depressor anguli oris resection. Depressor anguli oris resection led to a statistically significant increase in oral commissure median excursion, smile angle, and dental show [3.02 mm (p = 0.015), 1.70 degrees (p = 0.002), and 2.36 mm (p < 0.001), respectively]. Median Electronic Facial Paralysis Assessment and Facial Clinimetric Evaluation Scale instrument scores also improved [6.0 (p = 0.001) and 7.5 (p = 0.013), respectively]. Depressor anguli oris resection also led to more symmetric smiles. No correlation was seen between duration of follow-up and change in metrics., Conclusion: Depressor anguli oris resection is a minimal-risk procedure that frequently results in improved smile dynamics, smile symmetry, and quality of life in patients with nonflaccid facial palsy., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: A commonly seen issue in facial palsy patients is brow ptosis caused by paralysis of the frontalis muscle powered by the frontal branch of the facial nerve. Predominantly, static methods are used for correction. Functional restoration concepts include the transfer of the deep temporal branch of the trigeminal nerve and cross-facial nerve grafts. Both techniques can neurotize the original mimic muscles in early cases or power muscle transplants in late cases. Because axonal capacity is particularly important in cross-facial nerve graft procedures, the authors investigated the microanatomical features of the frontal branch to provide the basis for its potential use and to ease intraoperative donor nerve selection., Methods: Nerve biopsy specimens from 106 fresh-frozen cadaver facial halves were obtained. Histologic processing and digitalization were followed by nerve morphometric analysis and semiautomated axon quantification., Results: The frontal branch showed a median of three fascicles (n = 100; range, one to nine fascicles). A mean axonal capacity of 1191 ± 668 axons (range, 186 to 3539 axons; n = 88) and an average cross-sectional diameter of 1.01 ± 0.26 mm (range, 0.43 to 1.74 mm; n = 67) were noted. In the linear regression model, diameter and axonal capacity demonstrated a positive relation (n = 57; r2 = 0.32; p < 0.001). Based on that equation, a nerve measuring 1 mm is expected to carry 1339 axons., Conclusion: The authors' analysis on the microanatomy of the frontal branch could promote clinical use of cross-facial nerve graft procedures in frontalis muscle neurotization and free muscle transplantations., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Depressor anguli oris muscle hypertonicity in synkinetic facial paralysis patients may have an overpowering antagonistic effect on facial symmetry. Depressor anguli oris muscle block is a crucial diagnostic test before any treatment planning. Presented is the largest patient cohort analysis to date on static and dynamic facial symmetry changes after depressor anguli oris muscle block., Methods: Unilateral synkinetic patients with depressor anguli oris muscle hypertonicity were included. Resting symmetry and smile modiolus angle, excursion, and exposure of teeth were measured on both synkinetic and healthy hemifaces before and after depressor anguli oris muscle block using Emotrics and FaceGram photographic analyses., Results: Thirty-six patients were included. Before depressor anguli oris block, resting modiolus height was elevated on the synkinetic side (p = 0.047). During open-mouth smile, reduced modiolus angle (p < 0.0001), modiolus excursion (p < 0.0001), and exposure of teeth (p < 0.0001) were observed on the synkinetic hemiface. After depressor anguli oris block, resting modiolus height became symmetric (p = 0.64). During open-mouth smile, modiolus angle and exposure of teeth significantly increased (both p < 0.0001); excursion did not improve on the synkinetic side (p = 0.13) but unexpectedly improved in open-mouth smile on the healthy side (p = 0.0068)., Conclusions: Depressor anguli oris muscle block improved resting symmetry and modiolus angle and exposure of teeth during smile, demonstrating the inhibitory mimetic role of a hypertonic depressor anguli oris muscle in synkinesis. It is a critical diagnostic and communication tool in the assessment and treatment planning of depressor anguli oris muscle hypertonicity, suggesting the potential effects of future depressor anguli oris myectomy., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Lengthening temporalis myoplasty, described by Daniel Labbe in 1997, is a facial reanimation procedure for the treatment of facial nerve palsy. It involves the mobilization of temporalis muscle antero-inferiorly, and the insertion of its tendon at the nasolabial fold-oral commissure region. Knowledge of the temporalis muscle is crucial in performing this procedure; however, previous anatomical studies are limited. This study on cadavers, aimed to describe the anatomical location of the temporalis muscle insertion in relation to the adjacent structures, and its main pedicle to aid surgeons in performing this procedure. Twenty-four temporalis muscles were dissected in 12 fresh frozen cadavers. The anatomical location of the temporalis muscle insertion, accessory attachments, the emergence of the posterior deep temporal artery, and the distance of sliding movements from the coronoid process to the nasolabial fold were recorded. In addition to its origin from the temporalis fossa and its insertion at the coronoid process, the temporalis muscle was found to have multiple accessory attachments to adjacent structures. These findings explain the challenges in performing the sliding action without releasing the accessory attachments to the masseter and pterygoid muscles. The deep posterior temporal artery is located inferoposteriorly in relation to the muscle. Therefore, the muscle elevation maneuver performed without direct vision can be done with minimal risk to the muscle pedicle. The knowledge of temporalis muscle insertion, its accessory attachments, and its main pedicle will facilitate surgeons in performing the lengthening temporalis myoplasty more confidently., Competing Interests: Declaration of Competing Interest The authors declare they have no conflicts of interest in relation to this article., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Microneurovascular free muscle transfer is the gold-standard surgical procedure for the reanimation of established facial paralysis. However, the innervation of the transferred muscle by the contralateral facial nerve is usually insufficient to produce a stable smile. Besides, the corner of the mouth sometimes moves unnaturally as if it were being pulled up because of the single-direction movement. Thus, we propose one-stage facial reanimation using free latissimus dorsi (LD)-serratus anterior (SA) combined muscle flap transfer with dual innervation. The LD-SA combined muscle flap was harvested with the thoracodorsal artery and vein as common vessels to move the corner of the mouth bidirectionally for natural smiling. The LD muscle was located in the same direction as the zygomaticus major muscle and reinnervated by dual innervation. The contralateral facial nerve was coapted with the thoracodorsal nerve, and the ipsilateral masseter motor nerve was inserted into the LD muscle by intramuscular neurotization. The 6th or 7th SA muscle was located in the same direction as the risorius muscle and reinnervated by neurorrhaphy of the long thoracic nerve and the thin branch of the ipsilateral masseter motor nerve. Since 2015, seven patients have been treated with this method without complications. On average, SA muscle movement was detected in voluntary biting at 3.1 months, and spontaneous smiling occurred 7.7 months after surgery. All patients developed a spontaneous natural smile. This method for established facial paralysis has the potential to improve the quality of the reconstructed smile and the unstable results of conventional single-innervation-single-muscle transfer., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: To investigate the effect of the artificial facial nerve on the restoration of orbicularis oculi muscle function for unilateral peripheral facial paralysis in rabbit. Methods: Artificial facial nerve was implanted into the rabbit with unilateral peripheral facial paralysis between January 2018 and May 2019. At different time points after operation, the affected orbicularis oculi muscles' stimulation closure threshold and the synchronism about the motion of the two sides of orbicularis oculi muscles were monitored. T test was used with SPSS 13.0 software. Results: There was no significant difference in the closure threshold of the orbicularis oculi muscle on the 7th and 28th days after artificial facial nerve implantation ( P> 0.05). The synchronism of the normal side eye closing movement triggered the affected orbicular oculi muscle movement with the artificial facial nerve was up 19/20 to 20/20 at different times. Conclusions: The artificial facial nerve system had the features of stable working condition and high synchronizing effect for stimulating movement. It could restore the closed eye function in animals with peripheral facial paralysis animals and had great clinical application prospects.

Background: Corneal protection is a priority in flaccid facial palsy patients. Denervation of the orbicularis oculi muscle results in weak palpebral closure and predisposes patients to severe corneal sequelae. While periorbital static procedures enhance corneal coverage in repose, voluntary closure is only regained through dynamic reinnervation of the muscle. This study aims to elucidate the added effect of dynamic reinnervation of the orbicularis oculi muscle on long-term corneal integrity as well as on dynamic closure of the palpebral aperture., Methods: Retrospective review was performed on two groups of complete palsy patients: those who received solely periorbital static procedures and those who underwent concomitant orbicularis oculi muscle reinnervation and static lid procedures. Only patients with complete ophthalmic examinations were included. Corneal punctate epithelial erosions in addition to static and dynamic palpebral measurements were serially assessed preoperatively and postoperatively., Results: Of 272 facial palsy patients, 26 fit the inclusion criteria. Eleven patients underwent combined muscle reinnervation involving facial-to-masseteric nerve coaptation in addition to static eye procedures, and 15 patients underwent solely static interventions. Analysis revealed a 65.3 percent lower mean punctate epithelial erosion score in reinnervation patients as compared with static patients when evaluated at more than 9 months postoperatively (p < 0.01). Reinnervation patients were also found to have 25.3 percent greater palpebral aperture closure (p < 0.05) and 32.8 percent higher closure velocity (p < 0.01) compared with static patients., Conclusion: In patients with subacute facial palsy, dynamic reanimation of the orbicularis oculi muscle with concomitant static interventions provides lasting corneal protection not seen in patients who receive solely static interventions., Clinical Question/level of Evidence: Therapeutic, III.

The masseteric nerve (MN) and the anterior branch of the obturator nerve (ON) that innervate the transferred gracilis muscle have proved highly efficient for reanimating paralyzed facial muscles when muscle transfer is required. Previous researchers have published the total axonal load for myelinated fibers in both nerves. However, the real motor axonal load has not been established. We performed the study on 20 MN and 13 ON. The segments of the MN and the ON were embedded in paraffin, sectioned at 10 μm, and stained following a standard immunohistochemical procedure using anti-choline acetyltransferase to visualize the motor fibers. The MN has a higher axonal load than the ON. There were statistically significant differences between the axonal load of the proximal segment of the MN and the ON. These findings confirm that end-to-end anastomoses between the MN and the ON should preferably use the proximal segment. However, MN neurotomy should ideally be performed between the proximal and distal segments, preserving innervation to the deep fascicles. Our results show that the MN is ideal as a donor motor nerve for reinnervating transplanted muscle for dynamic reanimation of the paralyzed face. The neurotomy should ideally be performed between the first and second collateral branches of the MN. Clin. Anat. 32:612-617, 2019. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Introduction: The techniques of facial reanimation are continually evolving in search of the ideal method for rehabilitating the paralyzed face. In the past, alternative cranial nerve motor nuclei have been used to power facial musculature. The trigeminal nerve is gaining popularity as a promising nerve to drive facial motion, particularly in the lower face., Objectives: This article describes a low-tension technique of using the transposed facial nerve to the trigeminal nerve (masseteric branch) for facial reanimation., Methods: Six patients over 2.5 years were treated with facial nerve translocation with division at the geniculate and direct neurorrhaphy to the motor branch of the masseter. Patients were evaluated by physical examination, measurement of oral commissure excursion using MEEI FACE-gram software, video assessment, Sunnybrook Facial Grading System, Facial Disability Index, and Facial Clinimetric Evaluation Scale (FaCE)., Results: Patients demonstrated early motion within 4 months postoperatively and were placed into facial physical therapy. All demonstrated improvements in oral competence, strong oral commissure excursion with good symmetry, speech improvements, and variable results in facial tone. Synkinesis to the smile antagonists in the lower face was noted and treated with chemodenervation in three of six. No upper division synkinesis was noted., Conclusion: The motor branch of the trigeminal nerve is an effective option for facial reanimation via facial nerve translocation and end-to-end neurorrhaphy. Variable results in facial tone were noted with excellent oral commissure excursion. This procedure is safe in the reoperated mastoid.

Various donor muscles have been identified for restoring facial function due to longstanding facial paralysis. Donor muscles such as the gracilis and latissimus dorsi are frequently used and often produce one or two reliable vectors of force. However, there are drawbacks of using these muscles, including the instability of separating multivector functioning muscle units and limited amount of muscle contraction. Serratus anterior muscle transfer has the advantages of multiple independently functioning motor units that can be created with a single neurovascular pedicle. This article describes multivector muscle transfer using two or three superficial subslips of the serratus anterior muscle on a single neurovascular pedicle to produce an esthetic smile that is customized to imitate the function of the contralateral mimetic muscles. Twelve patients who had longstanding unilateral facial paralysis underwent muscle transfer consisting of multivector superficial subslips of the serratus anterior muscle innervated by the ipsilateral masseteric nerve. The procedure had an uneventful postoperative course, and patients obtained excellent results, with sufficient upper lip excursion, mouth angle, and lower lip working simultaneously. Functioning muscle transfer using multivector superficial subslips of the serratus anterior muscle is effective for treating longstanding facial paralysis. This technique avoids postoperative bulkiness of the cheek muscle and achieves a more natural and symmetrical smile., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The field of facial paralysis requires the reconstructive surgeon to apply a wide spectrum of reconstructive and aesthetic principles, using a comprehensive array of surgical tools, including microsurgery, peripheral nerve surgery, and aesthetic facial surgery on the road to optimize patient outcomes. The distinct deficits created by different anatomical levels of facial nerve injury require a fundamental understanding of facial nerve anatomy. Palsy duration, followed by location and mechanism, will determine mimetic muscle salvageability, by means of either direct repair, grafting, or nerve transfers, whereas longer palsy durations will necessitate introducing a new neuromuscular unit, whether by muscle transfer or free functional muscle transplant. A thorough history, physical examination, and basic understanding of ancillary studies, emphasizing palsy duration, location, and mechanism of injury, are critical in evaluation, prognostication, and treatment strategies in traumatic facial palsy patients. The importance of ancillary and aesthetic procedures cannot be overstated. Although these do not provide motion, they constitute essential tools in the treatment of facial paralysis, providing both protective and improved aesthetic outcomes, yielding the highest impact in final surgeon and patient satisfaction, bringing our patients to smile not only on the outside, but also on the inside.

Facial expressions play a fundamental role in interpersonal communication and interaction; consequently, facial palsy has profound effects on the quality of life of patients. Reanimation of lower lip depressors is rarely addressed during facial reanimation but is as important as treating the eye sphincter and the lip levators. Depressors of lower lip are vital for full denture smile and the expression of facial emotions. Static and dynamic techniques are used to reanimate the lower lip depressors. Static techniques provide stationary results either by weakening the contralateral normal side to achieve symmetry using botulinum toxin injection, depressor labi inferioris myectomy and marginal mandibular nerve neurectomy, or by creating static slings and tightening procedures on the affected side. Dynamic techniques provide functional results by reanimating the affected depressor complex using nerve transfers, muscle transfers, and direct muscle neurotization. The purpose of this article is to present an overview of the literature on the applications of these techniques in lower lip reanimation. Furthermore, preoperative evaluation and indications are also discussed.

Facial paralysis is a condition caused by a wide variety of etiologies, including neurologic, congenital, infectious, neoplastic, systemic, and iatrogenic causes. A patient suffering from long-term facial paralysis, with minimal innervation detected through electroneurography, who was successfully reanimated by performing a masseter-to-facial nerve transfer, was presented in this study. Facial paralysis had been caused after resection of an acquired middle ear cholesteatoma more than 5 years before.

Background: Single-stage latissimus dorsi neuromuscular transfer has been a valuable option for dynamic smile reanimation. However, there is a paucity of studies evaluating the potential donor morbidity in such cases. The present study aimed to comprehensively analyze the donor morbidity following functional latissimus dorsi muscle transfer., Methods: Patients who underwent single-stage functional latissimus dorsi muscle transfer for smile reanimation between 2002 and 2016 were reviewed. Postoperative complications and functional impairments at the donor sites were evaluated. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was used for assessing postoperative donor-site function., Results: Sixty patients, including 12 pediatric (18 years or younger) patients, were analyzed. Mean length of a harvested thoracodorsal nerve was 14.9 cm. Fourteen patients were treated with a dual innervation technique, in which both a descending and a transverse branch of the thoracodorsal nerve were harvested. Donor complications were observed in seven cases; all of them were seromas and resolved by simple aspiration. No other complications including scoliosis and sensory and/or motor disturbances in the upper extremities were encountered. Fifty patients responded to the Quick-Disabilities of the Arm, Shoulder and Hand questionnaire at a median follow-up of 51 months. The average score was 2.64, and all but three patients scored less than 10. No variables, including patient age (pediatric versus adult) and the use of a dual-innervation technique, affected the donor morbidities, including the functional deficits., Conclusion: Single-stage latissimus dorsi neuromuscular transfer for facial reanimation might be associated with a low rate of complications and minimal functional morbidity at the donor site., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The human smile is a complex coordinated activity of mimetic muscles predominantly recognizable by a superolateral pull at the commissure and elevation of the upper lip. The aim of this study was to revisit the muscles of facial expression responsible for these motions, evaluate their relational anatomy and orientation, and relate this to optimal positioning of free muscle transfer in smile reanimation., Methods: Nineteen hemifaces from fresh cadaveric specimens were dissected. A subsuperficial muscular aponeurotic system skin flap was elevated to expose the zygomaticus major, zygomaticus minor, levator labii superioris, and levator labii superioris alaeque nasi. Muscle location, length, width, angle of pull, and any anatomic variation were noted., Results: All specimens had zygomaticus major, levator labii superioris, and levator labii superioris alaeque nasi muscles present bilaterally. Conversely, the zygomaticus minor was present in only 10 of 19 hemifaces. There was no significant difference in muscle length, width, or line of pull between specimen sides. Of all the assessed muscles, the zygomaticus minor had the most transverse line of pull, at 31.6°; the zygomaticus major was more oblique with a line of pull of 55.5°; and the levator labii superioris and levator labii superioris alaeque nasi were oriented almost vertically with angles of 74.7° and 79.0°, respectively., Conclusions: The mimetic muscle vector is quite vertical in comparison to the angle obtained by traditional dynamic smile reconstruction surgeries. A more vertical vector, especially at the upper lip, should be considered in smile reconstruction.

Facial reanimation provides patients affected by chronic facial paralysis a chance to regain basic human functions such as emotional expression, verbal communication, and oral competence for eating and swallowing, but there is still no consensus as to the best way to measure surgical outcomes. We performed a literature review to investigate the different functional outcomes that surgeons use to evaluate facial function after reanimation surgery, focusing on outcomes other than facial expressions such as speech, oral competence, and patient quality of life/satisfaction. A total of 37 articles were reviewed, with the majority reporting outcomes through subjective facial expression ratings and only 15 dealing with other functional outcomes. In particular, outcomes related to oral competence and speech were reported inconsistently. Facial reanimation patients would benefit from a unified movement to create and validate through consensus, an outcomes reporting system incorporating not only facial expression, but also oral competence, speech, and patient-reported quality of life, to enable global patient assessment., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background: To reanimate the mimetic muscles, crossface nerve graft (CFNG) is an effective surgical option. However, muscle atrophy after facial paralysis may influence the surgical result. We analyzed the relationship between surgical result and preoperative paralysis duration., Methods: We performed CFNG on 15 patients. The sural nerve was transferred between the affected and nonaffected sides of the zygomatic branch. Eyelid function and eyelid lid were evaluated using the modified House-Brackmann scale. The effects of age, sex, cause of facial paralysis, graft nerve length, and preoperative paralysis duration were evaluated., Results: The mean follow up period was 9.3 ± 3.3 (range 4-14) years. Eyelid closure was excellent in four patients, good in six, fair in one, and poor in four. Statistically, no significant difference was observed between those patients with excellent or good outcomes and fair or poor outcomes regarding age (40.9 ± 11.0 years vs. 22.6 ± 20.8; P = .067), sex (male/female = 2/8 vs. 3/2; P = .250), cause (tumor/trauma = 10/0 vs. 3/2; P = .095), and length of nerve graft (14.4 ± 0.8 cm vs. 13.8 ± 1.6 cm; P = .375). The average preoperative paralysis duration in the excellent/good patients was significantly shorter than that in the fair/poor patients (P = .005). All eight cases with preoperative paralysis of less than 6 months showed a marked excellent/good result. Two of the seven patients with preoperative paralysis was 6 months or longer marked fair/poor result. (P = .007)., Conclusions: To achieve successful results with CFNG, surgery should be performed within 6 months of the onset of paralysis., (© 2017 Wiley Periodicals, Inc.)

In reanimation surgery, effortless smile can be achieved by a nonfacial donor nerve. The underlying mechanisms for this smile development, and which is the best nonfacial neurotizer, need further clarification. The aim of the present study was therefore to further explore the natural coactivation between facial mimic muscles and muscles innervated by the most common donor nerves used in smile reanimation. The study was conducted in 10 healthy adults. Correlation between voluntary facial muscle movements and simultaneous electromyographic activity in muscles innervated by the masseter, hypoglossal, and spinal accessory nerves was assessed. The association between voluntary movements in the latter muscles and simultaneous electromyographic activity in facial muscles was also studied. Smile coactivated the masseter and tongue muscles equally. During the seven mimic movements, the masseter muscle had fewer electromyographically measured coactivations compared with the tongue (two of seven versus five of seven). The trapezius muscle demonstrated no coactivation during mimic movements. Movements of the masseter, tongue, and trapezius muscles induced electromyographically recorded coactivation in the facial muscles. Bite resulted in the strongest coactivation of the zygomaticus major muscle. The authors demonstrated coactivation between voluntary smile and the masseter and tongue muscles. During voluntary bite, strong coactivation of the zygomaticus major muscle was noted. The narrower coactivation pattern in the masseter muscle may be advantageous for central relearning and the development of a spontaneous smile. The strong coactivation between the masseter muscle and the zygomaticus major indicates that the masseter nerve may be preferred in smile reanimation.

Background and Objectives: Early persistent facial paralysis is characterized by intact muscles of facial expression through maintained perfusion but lacking nerve supply. In facial reanimation procedures aiming at restoration of facial tone and dynamics, neurotization through a donor nerve is performed. Critical for reanimating target muscles is axonal capacity of both donor and recipient nerves. In cases of complete paralysis, the proximal stump of the extratemporal facial nerve trunk may be selected as a recipient site for coaptation. To further clarify the histological basis of this facial reanimation procedure we conducted a human cadaver study examining macro and micro anatomical features of the facial nerve trunk including its axonal capacity in human cadavers. Axonal loads, morphology and morbidity of different donor nerves are discussed reviewing literature in context of nerve transfers., Methods: From 6/2015 to 9/2016 in a group of 53 fresh frozen cadavers a total of 106 facial halves were dissected. Biopsies of the extratemporal facial nerve trunk (FN) were obtained at 1 cm distal to the stylomastoid foramen. After histological processing and digitalization of 99 specimens available, 97 were selected eligible for fascicle counts and 87 fulfilled quality criteria for a semi-automated computer-based axon quantification software using ImageJ/Fiji., Results: An average of 3.82 fascicles (range, 1 to 9) were noted (n = 97). 6684±1884 axons (range, 2655- 12457) were counted for the entire group (n = 87). Right facial halves showed 6364±1904 axons (n = 43). Left facial halves demonstrated 6996±1833 axons (n = 44) with no significant difference (p = 0.73). Female cadavers featured 6247±2230 (n = 22), male showed 6769±1809 axons (n = 40). No statistical difference was seen between genders (p = 0.59). A comparison with different studies in literature is made. The nerve diameter in 82 of our specimens could be measured at 1933±424 μm (range, 975 to 3012)., Conclusions: No donor nerve has been described to match axonal load or fascicle number of the extratemporal facial nerve main trunk. However, the masseteric nerve may be coapted for neurotization of facial muscles with a low complication rate and good clinical outcomes. Nerve transfer is indicated from 6 months after onset of facial paralysis if no recovery of facial nerve function is seen.

Objective: Details regarding the molecular biological features of Bell's palsy have not been widely reported in textbooks. We genetically analyzed facial muscles and clarified these points., Materials and Methods: We performed genetic analysis of facial muscle specimens from Japanese patients with severe (House-Brackmann facial nerve grading system V) and moderate (House-Brackmann facial nerve grading system III) dysfunction due to Bell's palsy. Microarray analysis of gene expression was performed using specimens from the healthy and affected sides, and gene expression was compared. Changes in gene expression were defined as an affected side/healthy side ratio of >1.5 or <0.5., Results: We observed that the gene expression in Bell's palsy changes with the degree of facial nerve palsy. Especially, muscle, neuron, and energy category genes tended to fluctuate with the degree of facial nerve palsy., Conclusion: It is expected that this study will aid in the development of new treatments and diagnostic/prognostic markers based on the severity of facial nerve palsy.

Objective Evaluate outcomes of the lengthening temporalis myoplasty in facial reanimations. Study Design Case series with planned data collection. Setting Ospedali Riuniti, Bergamo, and AOUC Careggi, Florence, Italy. Subjects and Methods From 2011 to 2016, 11 patients underwent lengthening temporalis myoplasty; demographic data were collected for each. Pre- and postoperative photographs and videos were recorded and used to measure the smile angle and the excursion of the oral commissure, according to the SMILE system (Scaled Measurements of Improvement in Lip Excursion). All patients were tested with the Facial Disability Index, and they also completed a questionnaire about the adherence to physiotherapy indications. Results All patients demonstrated a significant improvement in functional parameters and in quality of life. On the reanimated side, the mean z-line and a-value, measured when smiling, significantly improved in all patients: from 22.6 mm (95% CI, 20.23-25.05) before surgery to 30.9 mm (95% CI, 27.82-33.99) after surgery ( P < .001) and from 100.5° (95% CI, 93.96°-107.13°) to 111.6° (95% CI, 105.63°-117.64°; P < .001), respectively. The mean postoperative dynamic gain, passing from rest to a full smile at the reanimated side, was 3.1 mm (95% CI, 1.30-4.88) for the z-line and 3.3° (95% CI, 1.26°-5.29°) for the a-value. The Facial Disability Index score increased from a preoperative mean of 33.4 points (95% CI, 28.25-38.66) to 49.9 points (95% CI, 47.21-52.60) postoperatively ( P < .001). Conclusions The lengthening temporalis myoplasty can be successfully used for smile reanimation, with satisfying functional and quality-of-life outcomes.

Background: This report describes the results of a surgical procedure for facial reanimation. This single-stage technique involves the orthodromic transfer of only a superficial segment of the temporalis tendon. This is extended with fascia lata to achieve elevation of the oral commissure along the desired vector in the paralysed hemi-face., Methods: A retrospective case note review was performed. Patients' photographs were objectively evaluated with Facial Assessment by Computer Evaluation (FACE) software., Results: Thirty-nine patients underwent the procedure from 2001 to 2011. Median age at the operation was 57.0 years (interquartile range (IQR) 38.2-66.3 years), and median duration of follow-up was 0.9 years (IQR 0.5-1.8 years). All patients achieved early improvements in appearance and function after surgery. Three patients underwent further, minor procedures for aesthetic and functional adjustments around the oral commissure. Complications occurred in three patients: two minor facial haematomas and one thigh wound infection. The surgery did not disturb natural temporalis muscle function. FACE analysis demonstrated that no significant movement of the oral commissure occurred during attempted smiling in the paralysed hemi-face before surgery. However, symmetry was achieved when the healthy and paralysed hemi-faces were compared post-operatively, both in repose and during controlled smiling., Conclusions: This modified, single-stage technique for facial reanimation improves commissure mobilisation and has been objectively shown to restore symmetry of the commissure to the reanimated hemi-face., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Many investigators study facial nerve regeneration using the rat whisker pad model, although widely standardized outcomes measures of facial nerve regeneration in the rodent have not yet been developed. The intrinsic whisker pad "sling" muscles producing whisker protraction, situated at the base of each individual whisker, are extremely small and difficult to study en bloc. Here, we compare the functional innervation of 2 potential reporter muscles for whisker pad innervation: the dilator naris (DN) and the levator labii superioris (LLS), to characterize facial nerve regeneration., Methods: Motor supply of the DN and LLS was elucidated by measuring contraction force and compound muscle action potentials during stimulation of individual facial nerve branches, and by measuring whisking amplitude before and after DN distal tendon release., Results: The pattern of DN innervation matched that of the intrinsic whisker pad musculature (ie, via the buccal and marginal mandibular branches of the facial nerve), whereas the LLS seemed to be innervated almost entirely by the zygomatic branch, whose primary target is the orbicularis oculi muscle., Conclusions: Although the LLS has been commonly used as a reporter muscle of whisker pad innervation, the present data show that its innervation pattern does not overlap substantially with the muscles producing whisker protraction. The DN muscle may serve as a more appropriate reporter for whisker pad innervation because it is innervated by the same facial nerve branches as the intrinsic whisker pad musculature, making structure/function correlations more accurate, and more relevant to investigators studying facial nerve regeneration.

Background: The treatment of long-standing facial palsy represents a challenge for the reconstructive surgeon. Treatment is based on dynamic procedures such as functional muscle flaps. The benefit of added axonal load has recently been reported. This study describes a two stage technique involving dual innervation of a gracilis muscle flap with initial cross-facial nerve graft (CFNG) followed by free muscle transfer co-apted to both the CFNG and a masseter nerve for facial reanimation., Methods: A total of nine patients from August 2008-July 2011 were operated on with the double innervated gracilis muscle flap. Pre- and postoperative electromyography was documented, and video analysis with the five-stage classification of reanimation outcomes was performed., Results: All patients recovered voluntary and spontaneous smile abilities, with an average of 70% motor unit recruitment. Based on the Terzis reanimation outcome classification, four patients had an excellent result, four good, and one moderate., Conclusions: The double innervated gracilis muscle flap is a viable technique for the treatment of long-standing facial palsy. It enables a fast recovery with fast muscle activity, and allows an emotional smile and aesthetic symmetry.

Facial paralysis following acoustic neuroma (AN) resection can be devastating, but timely and strategic intervention can minimize the resulting facial morbidity. A central strategy in reanimating the paralyzed face after AN resection is to restore function of the native facial muscles using available facial nerves or repurposed cranial nerves, mainly the hypoglossal or masseter nerves. The timing of reinnervation is the single most influential factor that determines outcomes in facial reanimation surgery. The rate of recovery of facial function in the first 6 months following AN resection may be used to predict ultimate facial function. Patients who show no signs of recovery in the first 6 months, even when their facial nerves are intact, recover poorly and are candidates for early facial reinnervation. With delay, facial muscles become irreversibly paralyzed. Reanimation in irreversible paralysis requires the transfer of functional muscle units such as the gracilis or the temporalis muscle tendon unit., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Free functional muscle transfer to the face is a standard of facial animation. The contralateral facial nerve, via a cross-face nerve graft, provides spontaneous innervation for the transferred muscle, but is not universally available and has additional shortcomings. The motor nerve to the masseter provides an alternative innervation source. In this study, the authors compared donor nerve histomorphometry and clinical outcomes in a single patient population undergoing free muscle transfer to the face., Methods: Pediatric patients undergoing dynamic facial (re-)animation with intraoperative nerve biopsies and gracilis transfer to the face powered by either the contralateral facial nerve via a cross-face nerve graft or the motor nerve to the masseter were reviewed over a 7-year period. Myelinated nerve counts were assessed histomorphometrically, and functional outcomes were evaluated with the Scaled Measurement of Improvement in Lip Excursion software., Results: From 2004 to 2011, 91 facial (re-)animation procedures satisfied study inclusion criteria. Average myelinated fiber counts were 6757 per mm2 in the donor facial nerve branch, 1647 per mm in the downstream cross-face nerve graft at the second stage, and 5289 per mm in the masseteric nerve. Reconstructions with either innervation source resulted in improvements in oral commissure excursion and smile symmetry, with the greatest amounts of oral commissure excursion noted in the masseteric nerve group., Conclusions: Facial (re-)animation procedures with use of the cross-face nerve graft or masseteric nerve are effective and result in symmetric smiles. The masseteric nerve provides a more robust innervation source and results in greater commissure excursion., Clinical Question/level of Evidence: Therapeutic, III.

Background: There are several techniques available for facial reanimation, but clinicians do not have a simple tool to provide an objective and quantitative spatial-temporal analysis of facial movement in order to compare medical, surgical and physical therapy., Methods: We developed specialized software capable of simultaneously tracking the position over time of a number of anatomical points. This method was tested in 5 different clinical situations: one normal subject, and 4 patients with facial disfigurement., Results: A large amount of quantitative information can be extracted directly, such as symmetry assessment in the contraction and relaxation trajectories. The fact that this plot is on scale allows also direct measurements such as maximal extensions. Even smiles that at the macro-scale are essentially symmetrical show at the micro-scale small asymmetries/variability., Conclusion: In this paper, we describe a novel quantitative, reliable method, which accurately assesses the fundamental aspects of the facial excursion, incorporating spatial and temporal components., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Individuals with facial paralysis of 6 months or more without evidence of clinical or electromyographic improvement have been successfully reanimated utilizing an orthodromic temporalis transfer in conjunction with end-to-side cross-face nerve grafts. The temporalis muscle insertion is released from the coronoid process of the mandible and sutured to a fascia lata graft that is secured distally to the commissure and paralyzed hemilip. The orthodromic transfer of the temporalis muscle overcomes the concave temporal deformity and zygomatic fullness produced by the turning down of the central third of the muscle (Gillies procedure) while yielding stronger muscle contraction and a more symmetric smile. The muscle flap is combined with cross-face sural nerve grafts utilizing end-to-side neurorrhaphies to import myelinated motor fibers to the paralyzed muscles of facial expression in the midface and perioral region. Cross-face nerve grafting provides the potential for true spontaneous facial motion. We feel that the synergy created by the combination of techniques can perhaps produce a more symmetrical and synchronized smile than either procedure in isolation., Methods: Nineteen patients underwent an orthodromic temporalis muscle flap in conjunction with cross-face (buccal-buccal with end-to-side neurorrhaphy) nerve grafts. To evaluate the symmetry of the smile, we measured the length of the two hemilips (normal and affected) using the CorelDRAW X3 software. Measurements were obtained in the pre- and postoperative period and compared for symmetry., Results: There was significant improvement in smile symmetry in 89.5 % of patients., Conclusion: Orthodromic temporalis muscle transfer in conjunction with cross face nerve grafts creates a synergistic effect frequently producing an aesthetic, symmetric smile., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

The standard method for managing chronic facial palsy is the two-stage free-muscle flap. We report a case involving a 25-year-old patient who had facial palsy from her birth. Twelve months after the first stage of a cross-facial nerve graft, we found that the voluntary movements of her facial muscles had returned. Within the following 12 months, she gained complete recovery of her movements on the affected side, as confirmed by electromyography studies. This case demonstrates that neurotization of facial muscles in chronic facial palsy is possible. However, further studies are needed to define the trophic effects or trophic mediators that can restore function to atrophied facial muscles and to determine which patients might benefit from the cross-facial nerve graft procedure without the free-muscle graft procedure.

Background: Upper eyelid reanimation is one of the most important aspects of facial paralysis. The ideal method would be one that provided dynamic restoration of voluntary eye closure, involuntary blinking, and corneal reflex. Innervation to the platysma has shown to be relatively consistent, which would allow its use as a muscle graft neurotized by the contralateral healthy facial nerve for eyelid reanimation., Methods: Six fresh cadavers, 12 sides, were studied by dissecting the main trunk of the facial nerve and its cervicofacial division. Special attention was paid at the emergence of cervical branches to the platysma and its distribution on the undersurface of the muscle as well as its relationships with regional anatomic references., Results: One major branch with 1 or 2 accessory branches was found to emerge from the cervicofacial division, 1.5 cm distal to its origin in the facial nerve trunk. The major branch showed an oblique course, starting approximately 1 cm below the angle of the mandible and coursing toward the inferomedial border of the muscle. Harvest of a 3 × 2 muscle piece with a 10-cm-long neural pedicle was possible in all specimens. When presented over the superior eyelid, the nerve branch was found to reach the contralateral frontal branch of the facial nerve., Conclusions: Innervation to the platysma muscle is relatively constant and consists of 1 major branch accompanied by 1 or 2 accessory branches. Harvest of a muscle flap with a neural pedicle long enough to reach the contralateral healthy side is anatomically feasible.

Purpose of Review: To present the most current literature regarding the management of acute and chronic facial paralysis. This review will focus primarily on smile reanimation in the setting of acute and chronic facial paralysis. The management of the flaccid and the hypertonic face will be discussed., Recent Findings: Recent developments include advances in neural repair with fibrin glue and the use of cadaveric nerve grafts as interposition grafts. Advances in nerve substitutes have been shown to limit donor-site morbidity and provide similar outcomes to autografts. Techniques for muscle transfer continue to evolve to improve smile outcomes., Summary: The goal of facial reanimation surgery is to restore meaningful facial movement. The goal should be to have quality-driven clinical practice guidelines to better facilitate patient care. This process must be initiated by facial reanimation surgeons deciding to use consistent outcome measures to report their results. Currently, it is impossible to make a direct comparison between different surgical techniques because of inconsistent methods of evaluation. Despite the lack of consistent quantitative evaluation, there have been many exciting advances in the field.

Background: The present study demonstrates our experience with a novel use of the Platysma in facial reanimation, as a balancing procedure by counteracting an overactive free muscle transfer, and improving oral continence by re-establishing the oral sphincter mechanism., Material and Methods: Twelve patients, nine female (75%) and three male (25%), with a mean age of thirty-eight years (range: 2-66) are presented. Of these, in seven patients (58%) who had excessive excursion of the free muscle, the contralateral pedicled platysma was transferred to counteract the excessive pull. Four patients (33%) underwent bilateral platysma transfer for oral sphincter restoration, while one (8%) had ipsilateral platysma transfer. Evaluation of aesthetic and functional results was performed by a panel of three independent observers, and the long term efficacy of the procedure was assessed through a patient questionnaire., Results: All patients demonstrated significant upgrading of their oral competence associated with eating, drinking and smiling, as it was confirmed by the behavioural analysis (p<0.01). Six of the ten patients that were available, responded to the Quality of Life Questionnaire. Five out of six were satisfied with their mouth appearance when they smile and five patients have a regular diet and without drooling., Conclusion: A novel use of Platysma transposition is described that can substitute for a paralysed orbicularis oris muscle in restoring oral sphincter function or to counter balance an excessively active free muscle that was previously transferred for smile restoration. This novel Platysma transfer technique is intended to be used as an adjunct to other reanimation procedures., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Longstanding unilateral facial paralysis is best addressed with microneurovascular muscle transplantation. Neurotization can be obtained from the cross-facial or the masseter nerve. The authors present a quantitative comparison of both procedures using the FACIAL CLIMA system., Methods: Forty-seven patients with complete unilateral facial paralysis underwent reanimation with a free gracilis transplant neurotized to either a cross-facial nerve graft (group I, n=20) or to the ipsilateral masseteric nerve (group II, n=27). Commissural displacement and commissural contraction velocity were measured using the FACIAL CLIMA system. Postoperative intragroup commissural displacement and commissural contraction velocity means of the reanimated versus the normal side were first compared using the independent samples t test. Mean percentage of recovery of both parameters were compared between the groups using the independent samples t test., Results: Significant differences of mean commissural displacement and commissural contraction velocity between the reanimated side and the normal side were observed in group I (p=0.001 and p=0.014, respectively) but not in group II. Intergroup comparisons showed that both commissural displacement and commissural contraction velocity were higher in group II, with significant differences for commissural displacement (p=0.048). Mean percentage of recovery of both parameters was higher in group II, with significant differences for commissural displacement (p=0.042)., Conclusions: Free gracilis muscle transfer neurotized by the masseteric nerve is a reliable technique for reanimation of longstanding facial paralysis. Compared with cross-facial nerve graft neurotization, this technique provides better symmetry and a higher degree of recovery., Clinical Question/level of Evidence: Therapeutic, III.

Introduction: The facial paralysis is a non-rare condition that has very disabling functional, morphological and psychological repercussions. The current gold standard in facial reanimation is revascularized re-innervated muscle transfers., Materials and Methods: In this paper, we report the results of a new method using the gracilis flap with a double innervation on the masseter motor nerve and the controlateral facial nerve via a sural graft in a single stage intervention, on a series of six patients., Results: No failure was observed. The average delay of a voluntary contraction was 3.8months, and 7.2months for a spontaneous one. Three of the six patients had "excellent" results according to the Terzis and Noah classification, two were classified as "good" and one "average"., Discussion: A choice is to be made between a method advocating a natural and spontaneous dynamicity (controlateral facial nerve stimulus) and a method focusing on the quality and quantity of contractions (ipsilateral trijeminal stimulus). In this new technique, we combine the two methods: a free gracilis transfer with a dual innervation on the healthy controlateral facial nerve via a sural graft, on one hand, and a second anastomosis on the ipsilateral masseter nerve, on the other hand., Conclusion: This new proposed method seems to be, according to our results, a reliable technique rallying voluntary contraction and emotional smile., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

To quantify the effects of facial palsy reanimation, 14 patients aged 17-66 years were analysed. All patients had unilateral facial paralysis, and were candidates for surgical masseteric to facial nerve anastomosis. Two patient groups were measured: seven patients were waiting for surgery, the other seven patients had already been submitted to surgery, and had regained facial mimicry. Each patient performed three facial animations: brow raise; free smile; lip purse. These were recorded using an optoelectronic motion analyser. The three-dimensional coordinates of facial landmarks were obtained, their movements were computed, and asymmetry indices calculated (differential movements between the two hemi-faces: healthy and paretic/rehabilitated). Before surgery, mobility was larger in the healthy than in the paretic side; after surgery, the differences were reduced (brow raise and lip purse), or even reversed (smile). Before surgery, lip purse was performed with significant labial asymmetry (p=0.042; larger healthy side movement). After surgery, asymmetry indices reduced. Total labial asymmetry during smiling was significantly different from 0 before surgery (p=0.018, larger healthy side movement). After surgery, all asymmetry indices became non-significant. Before surgery the lateral displacements of all labial landmarks were towards the healthy side, while they normalized after surgery., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The aim of this study was to present the authors' experience with facial reanimation in adult patients following tumor extirpation and to analyze the functional outcomes., Methods: From 1978 to 2006, 60 adult patients underwent facial reanimation for facial paralysis following tumor extirpation. There was one patient with bilateral facial paralysis. Thus, evaluation was carried out in 61 hemifaces. Three independent assessors evaluated the preoperative and postoperative videos using the Terzis grading scale for eye closure, smile, depressor, and overall aesthetic and functional outcomes. Preoperative and postoperative electromyographic interpretations and the effect of demographic variables were also evaluated., Results: There was significant improvement regarding preoperative versus postoperative outcomes for overall aesthesis and function. Good and excellent results were observed in 72.14 percent of the hemifaces (n = 44). The difference between preoperative and postoperative electromyographic results was of statistical significance (p < 0.0001) for each target reinnervated. Better results were observed in younger patients (≤ 35 years) (p = 0.023) and in early cases (p = 0.019)., Conclusions: : The results of this present series illustrate that age and denervation time correlate with the final functional outcome. Cross-facial nerve grafts should ideally be used in patients with denervation time less than 6 months or more than 2 years combined with muscle transfers. In patients with a denervation time between 6 months and 2 years, the use of the babysitter procedure can yield a superior outcome., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The use of an interpositional nerve graft (IPNG) between the facial and hypoglossal nerves for incomplete facial palsy has recently been reported. However, its mechanism has not been elucidated. We established a rat model of IPNG to study incomplete facial palsy and confirmed the direction of innervation through the grafted nerve with or without facial nerve injury., Methods: Twenty rats were divided into five groups (n = 4): a control group (group A), an incomplete facial palsy group (group B), an IPNG-treated group (group C), an incomplete facial palsy group treated with IPNG (group D) and an incomplete hypoglossal nerve palsy group treated with IPNG (group E). After surgery, mimetic muscle movement was evaluated using an original scoring system. Twelve weeks after surgery, the mimetic muscles of the tongue were injected with Fast Blue and DiI. Retrograde-labelled neurons were counted through the facial and hypoglossal nuclei, and mimetic muscle specimens stained with Masson's trichrome were examined., Results: Fast Blue-labelled neurons were noted in the hypoglossal nucleus in groups C and D, and DiI-labelled neurons within the facial nucleus were noted in groups C and E. The group D facial palsy score statistically exceeded the group B score., Conclusions: The results revealed that axonal regeneration through IPNG is bi-directional and is preferentially directed towards the injured side. Innervation from the hypoglossal nerve to mimetic muscles through IPNG prevents muscle atrophy and helps counter facial palsy., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

To compare quantitatively the results obtained after hemihypoglossal nerve transposition and microvascular gracilis transfer associated with a cross facial nerve graft (CFNG) for reanimation of a paralysed face, 66 patients underwent hemihypoglossal transposition (n = 25) or microvascular gracilis transfer and CFNG (n = 41). The commissural displacement (CD) and commissural contraction velocity (CCV) in the two groups were compared using the system known as Facial clima. There was no inter-group variability between the groups (p > 0.10) in either variable. However, intra-group variability was detected between the affected and healthy side in the transposition group (p = 0.036 and p = 0.017, respectively). The transfer group had greater symmetry in displacement of the commissure (CD) and commissural contraction velocity (CCV) than the transposition group and patients were more satisfied. However, the transposition group had correct symmetry at rest but more asymmetry of CCV and CD when smiling.

Aims: Lagophthalmos is the major functional complication of facial paralysis because, in the absence of treatment, it can lead to corneal scarring and blindness. This disorder can be treated in a number of ways, including levator lengthening by aponeurosis interposition, a technique developed by Paul Tessier. We assessed the benefits of this technique, and compared the results to those with other techniques, in particular, the use of gold implants., Materials and Methods: A total of 29 patients were operated by the same surgeon using levator lengthening by aponeurosis interposition as described by Paul Tessier. Aesthetic and functional results were assessed according to predefined criteria during patient consultation at 1 year and by the patients themselves (questionnaire). We reviewed other surgical techniques used to treat lagophthalmos and compared findings with previous international studies., Discussion: The use of a gold plate implant remains the most widely used technique for the treatment of lagophthalmos. Although the functional results are good, the implant is always visible, leading to the disappearance of the superior palpebral fold and a risk of exposure and therefore of infection. Levator lengthening, a technique developed by Paul Tessier, allows identical functional results to be obtained, but conserves a natural appearance of the upper eyelid. It is a simple surgical procedure associated with a low morbidity rate., Conclusion: The lengthening of the levator by aponeurosis interposition is a simple, reliable, and easily reproducible technique allowing treatment of paralytic lagophthalmos with good results, in terms of both function and aesthetics.

Background: Six hundred fifty-five cases of unilateral facial paralysis were treated by different surgical methods to achieve dynamic reanimation of facial muscle movement. In a retrospective study, the recovery of both truly spontaneous smile and facial muscle movement was evaluated independently., Methods: The authors performed 505 two-stage gracilis, one rectus abdominis, and 14 single-stage latissimus dorsi microneurovascular muscle transfers, in addition to 28 cross-facial facial nerve neurotization procedures. These procedures were based on neurotization of the paralyzed region by the contralateral healthy facial nerve. Procedures involving motor nerves or muscle beyond the territory of the facial nerve included 73 temporalis muscle transpositions, four lengthening temporalis myoplasty procedures, 26 neurotizations by the hypoglossal nerve, and four neurotizations by the spinal accessory nerve., Results: Patients treated by techniques based on the motor function of nerves other than the facial nerve did not recover spontaneous smile. Neurotization by the facial nerve, however, did result in the recovery of spontaneous smile in all satisfactory or better outcomes. Recovery of lip commissure movement based on neurotization by the contralateral healthy facial nerve was better than that of the remaining groups (p < 0.0001)., Conclusions: Temporalis muscle transposition and lengthening myoplasty are acceptable options for patients who are not good candidates for neurotization by the facial nerve. For the restoration of both truly spontaneous smile and facial muscle movement, free microneurovascular muscle transfer neurotized by the contralateral healthy facial nerve has become the authors' first-choice surgical technique., Clinical Question/level of Evidence: Therapeutic, IV.

Between April 1999 and April 2008, 37 patients with long-standing facial paralysis underwent a one-stage facial reanimation with neuromuscular free flaps: 28 patients (group A) underwent flap transposition only; 9 patients (group B) underwent a deep-planes lift (DPL) composed of the superficial muscoloaponeurotic system + parotid fascia at the time of facial reanimation. The postoperative and final results were compared between groups A and B, following the classification of Terzis and Noah (1997). Before the onset of contraction, only group B patients (100%) showed good or moderate symmetry at rest, while none of the patients of group A had a symmetric face. The respective final results for patients in groups A and B who already showed the onset of flap contraction were excellent in 28.6% and 44.5%, good in 42.9% and 33.3%, moderate in 10.7% and 22.2%, and fair or poor and fair in 17.8% and 0% of patients, respectively. The DPL allows immediate symmetry of the face at rest and contributes to upgrading the final static and dynamic results in facial reanimation with free muscular flaps., (Copyright © 2010 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: To describe cortical reorganization after classic hypoglossal-facial nerve anastomosis (HFA) (four patients), hypoglossal-facial nerve jump anastomosis (HFJA) (three patients), and facial nerve interpositional graft (FNIG) (three patients)., Study Design: Prospective case series., Methods: Functional magnetic resonance imaging (fMRI) was performed during lip and tongue movement using a block or an event-related design., Results: Despite the presence of some intersubject variability, the following general brain activation patterns were revealed: As expected, lip movements after FNIG led to selective brain activation in the original facial motor cortex, and lip movements after HFA were associated with activation in the hypoglossal motor cortex. Following HFJA, lip movements resulted in overlapping activation encompassing both the original facial and the hypoglossal motor cortex, but tongue movements led solely to strong activation within the original hypoglossal motor cortex. In contrast, tongue movements after HFA were associated with strong activation in the original hypoglossal motor cortex and weaker activation in the facial motor cortex., Conclusions: Direct facial nerve repair (FNIG) leads to restoration of the original cortical activation. A cross nerve suture (HFA or HFJA) changes cortical activation and leads to different patterns of cortical activation during lip and tongue movements., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

We present a pilot study to evaluate the benefit of static facial suspension with Silhouette sutures. We operated on a female patient with complete facial palsy secondary to otic tuberculosis. The patient has currently achieved satisfactory facial symmetry, mastication and speech production. As a result, self-esteem and social interaction have also been recovered. Static facial suspension with Silhouette sutures is an alternative to dynamic techniques in patients who do not wish to or cannot undergo those more complex surgeries., (Copyright © 2009 Elsevier España, S.L. All rights reserved.)