Evaluation of Long-Term Surgical and Patient-Reported Outcomes after Pediatric Facial Reanimation

BACKGROUND

Outcomes of pediatric facial reanimation beyond 10 years are not known. This cross-sectional study evaluated long-term surgical and patient-reported outcomes of adults who underwent smile reconstruction as children with either a cross-face nerve graft (CFNG) or masseter nerve transfer at least 10 years previously.

METHODS

Commissure excursion was quantified with FACE-Gram software at 3 time points: preoperatively, early postoperatively within 2 years, and at long-term follow-up. Patient-reported outcomes were evaluated with validated questionnaires (Facial Clinimetric Evaluation Scale, FACE-Q 1.0) and thematic analysis of semistructured interviews. Results are reported as median (interquartile range [IQR]).

RESULTS

A total of 42 patients were included (26 women and 16 men). Median long-term follow-up was 19.3 years (IQR, 8.8 years) for CFNG and 17.6 years (IQR, 5.8 years) for masseter nerve transfer. For both groups, commissure excursion increased significantly from preoperative to early postoperative time points and remained stable at long-term follow-up (P < 0.0001). Commissure excursion at long-term follow-up between the 2 groups was not significantly different (CFNG, 5.0 mm [IQR, 9.4 mm]; masseter nerve transfer, 8.4 mm [IQR, 4.1 mm]); P > 0.05). For patient-reported outcomes, median Facial Clinimetric Evaluation Scale score was 72 of 100, and 95% of respondents agreed with the statement "I am pleased with the result" on the FACE-Q 1.0. Overall quality of life was rated at 7 of 10 or greater by 97% of participants, and all participants would recommend the surgery to other children.

CONCLUSIONS

Pediatric facial reanimation with CFNG or masseter nerve transfer reliably improves commissure excursion with longevity beyond 10 years. Adult patients report overall high satisfaction and social functioning.

The Concept of Ideal Lips of Caucasian Female: An Anthropometric Analysis of the Lower Third of the Face

BACKGROUND

The demand for lip-redefining procedures has been rising in recent years, thus creating the need for reliable and detailed reference sources on aesthetic female lips. This study investigates the morphology of the lower third of the face, including the lips and jawline, of attractive young Caucasian females.

METHODS

A semi-automatic photogrammetric analysis of the faces of professional female photograph models (n=400) of the Caucasian race aged 18-39 was performed. Angular, linear, and surface area parameters were evaluated. A graphical summarization of the average facial shape of all analyzed attractive females was generated as an average body contours (ABC) image.

RESULTS

The height of the lower third of the face equaled 0.32 ± 0.02 of the total facial height. The average lip width was 48.06 ± 3.34 mm. The upper vermilion height was found to be significantly lower than the lower vermilion height (6.47 ± 1.36 vs. 11.64 ± 1.46 mm, p < 0.01). The lip obliquity angle was found to be 1.05° ± 0.79°. The area surface of the upper lip vermilion was considerably smaller than the vermilion of the lower lip (p < 0.01).

CONCLUSIONS

This is one of the largest studies on attractive Caucasian females' lips and lower face morphology. The data it provides, including the graphical presentation of the aesthetic lower face as an ABC image, may provide physicians with valuable guidelines for lips rejuvenation and reconstruction procedures.

LEVEL OF EVIDENCE III

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 www.springer.com/00266 .

Evaluation of Nasal Conditions on Sleep: Integrating Wearable Tech in Surgical Outcomes

Objective: The primary objective of this study was to explore and identify the impacts of nasal septum deviation and turbinate hypertrophy on respiratory function, sleep quality, and overall well-being. Additionally, the study aimed to establish the therapeutic efficacy of surgical intervention and comprehensively analyse the additional advantages of wearable sleep trackers when combined with established diagnostic techniques. Methods: A prospective cohort of 150 participants (75 with nasal septum deviation and 75 with turbinate hypertrophy) underwent surgical intervention. The NOSE scale, PSQI, SF-36, and wearable sleep tracker data were employed for pre- and post-surgical evaluations. Objective measurements, such as nasal airflow and acoustic rhinometry, were also used. Multivariate regression was utilised to identify potential predictors of post-surgical outcomes. Results: The cohort had a mean age of 41 years with evenly balanced gender distribution. Both conditions showed post-surgical improvements in respiratory function, sleep quality, and quality-of-life. Wearable sleep tracker data provided insights into REM sleep duration and interruptions during sleep. The results indicated significant disturbances in sleep patterns in individuals with nasal septum deviation before undergoing surgery. Duration of the nasal condition was found to be a significant factor in predicting outcomes. Conclusion: Nasal septum deviation and turbinate hypertrophy had a significant impact on sleep patterns, overall well-being, and respiratory function. Surgical interventions provided significant relief, and wearable sleep tracker integration provides deeper insights into sleep disorders. The study highlights the importance of early intervention and the benefit of modern technologies in clinical evaluations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04524-y.

The Emerging Role of Artificial Intelligence Tools for Outcome Measurement in Facial Reanimation Surgery: A Review

Importance: Surgeons treating facial paralysis with reanimation surgery measure the outcomes of surgery and adjust treatment to each patient's needs. Our objective is to review the current subjective facial paralysis assessment tools and the emerging computer-based objective analysis, which may involve artificial intelligence. Observations: In recent years, many new automated approaches to outcome measurement in facial reanimation surgery have been developed. Most of these tools utilize artificial intelligence to analyze emotional expression and symmetry of facial landmarks. Other tools have provided automated approaches to existing clinician-guided scales. Conclusions: Newly developed computer-based tools using artificial intelligence have been developed to both improve existing clinician-graded scales and provide new approaches to facial symmetry and emotional expressivity analysis.

Gracilis Muscle-Free Flap Objective Improvement of Oral Commissure Excursion in Facial Palsy Reanimation Surgery: Systematic Review and Meta-Analysis

Background: Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation. Objective: This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG. Methods: A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model. Results: Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm. Conclusions: There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.

Comparison of static and dynamic symmetry between masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer for complete facial paralysis

PURPOSE

In this study, facial symmetry was compared between the masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer (FMSAMT) methods.

METHODS

Eighteen patients with unilateral complete facial paralysis underwent facial reanimation surgery between April 2006 and July 2019. The masseter-innervated FMSAMT group (Group M, n = 8) underwent end-to-end coaptation with the ipsilateral masseter nerve in one stage. The dual-innervated FMSAMT group (Group D, n = 10) underwent end-to-end coaptation with the masseter nerve and end-to-side coaptation with the contralateral facial nerve via cross-face nerve graft. They were further divided into the one-stage (Group D1, n = 5) and two-stage (Group D2, n = 5) subgroups. The durations of periods until the first visible muscle contraction with clenching, first spontaneous smile, and the completion of resting tone were evaluated. The possibility of a spontaneous smile and symmetry of the midline and horizontal deviation at rest and during voluntary smiling were compared between each group.

RESULTS

Groups M and D differed significantly in the possibility of a spontaneous smile and improvement rate of midline deviation and horizontal deviation at rest (p < 0.001, p < 0.001, and p = 0.001, respectively) but not in the improvement rate of midline and horizontal deviation during voluntary smiling. The duration of the period until the completion of resting tone was significantly shorter in Group D1 than in Group D2 (p = 0.048); however, the possibility of a spontaneous smile and the improvement rate of midline and horizontal deviation were not significantly different.

CONCLUSIONS

Dual-innervated FMSAMT was effective in guaranteeing a symmetrical resting tone, voluntary smiling, and reproducing a spontaneous smile.

Evidence-Based Medicine: Facial Reanimation

This article provides a brief historical overview of the assessment instruments that have been developed to categorize the severity of disease in patients with facial palsy. Important advances in the quality of these instruments are discussed. The modern-day instruments that are commonly required for evidence-based patient assessment are then presented, with emphasis on the level of evidence of the studies that describe these instruments.

Contribution of the Synkinesis Assessment Questionnaire and the Sunnybrook Facial Grading System to the evaluation of synkinesis after peripheral facial palsy: A STROBE observational study

OBJECTIVES

The main aim of the study was to determine whether the perception of synkinesis by patients with peripheral facial palsy (PFP) matched their clinician's severity assessment. Secondary objectives comprised: (1) to determine whether objective measurement of synkinesis matched the patient's perception; and (2) is to identify factors influencing patients' perceptions.

METHODS

This retrospective study took place from January to May 2020. Forty patients (8 per PFP grade, I-V/VI; 20 women, 20 men) filled out the Synkinesis Assessment Questionnaire (SAQ) and were assessed on the Sunnybrook Facial Grading System (SFGS). Photographs were analyzed on MEEI-Facegram software.

RESULTS

Perceived synkinesis (total SAQ) matched objective grades (SFGS) (Z=2.89; P=0.004), especially for smiling (Z=3.84; P<0.001) and lip protrusion (Z=3.79; P<0.001). Synkinesis on lip protrusion was a more sensitive indicator of perceived synkinesis than synkinesis on smiling (Z=2.96; P=0.003). Duration (ρ=0.5137; P<0.001) and grade of PFP (Chi²=13.82; P=0.008) heightened the perception of synkinesis.

CONCLUSION

Patient-reported outcome measures (PROMs) such as the SAQ are relevant for clinical evaluation.

Facial reanimation using free partial latissimus dorsi muscle transfer: Single versus dual innervation method

The aim of the present study was to analyze the consequences of partial free latissimus dorsi muscle flap with nerve splitting technique (Partial LD transfer) for facial reanimation and compare outcomes according to innervation method (singer versus dual innervation). Patients with complete unilateral facial paralysis underwent either the single (ipsilateral masseteric nerve only) or dual (ipsilateral masseteric nerve plus contralateral buccal branch of the facial nerve) nerve innervation method for facial reanimation. An assessment was carried out to compare the outcomes between the single and dual innervation. Total of 21 patients were involved in this study. In the single innervation group, 7 out of 8 patients developed a voluntary smile. However, none were able to achieve a spontaneous smile. On the other hand, 9 out of 13 patients developed a voluntary smile and 3 out of 13 patients achieved a spontaneous smile. The mean increases of smile excursion assessed by Emotrics software and Terzis grades showed no significant differences between two groups. Within the limitations of the study it seems that partial LD transfer approach utilizing the dual innervation method has a positive effect on achieving a spontaneous smile and could be a valuable option for facial reanimation.

Surgical Treatment for Postparalytic Facial Synkinesis - A 35 Year Experience

BACKGROUND

Surgical intervention with Combined myectomy & neurectomy followed by functioning free muscle transplantation (FFMT) has been proposed to effectively resolve the problem of postparalytic facial synkinesis (PPFS) since 1985, and continues to be our standard-of-care. We aim to provide evidence that this surgical strategy is effective for treatment of synkinesis and smile quality.

METHODS

103 patients with PPFS were investigated (1985-2020). They all underwent extensive removal of the synkinetic muscles and triggered facial nerve branches in the cheek, nose and neck regions, followed by gracilis FFMT for facial reanimation. Ninety-four patients with 50 Type II and 44 Type III PPFS patients, all of whom had at least one year of postoperative follow-up were included in the study. Patient's demographics, functional and aesthetic evaluations before and after surgery were collected.

RESULTS

In the yearly distribution of the facial paralysis reconstruction, the incidence of surgical intervention increased from 15% prior to 2012 up to 24% in the years after. Young adults (79%) and female patients (63%) were the dominant population. Results showed a significant improvement of the facial smile quality with more teeth visible while smiling, and a long-lasting decrease of facial synkinesis. Ninety six percent of patients did not require botulinum-A toxin injection after surgery. Revision surgery for secondary deformity was 53%.

CONCLUSION

Combined myectomy & neurectomy followed by FFMT for Type II and III synkinetic patients leads to promising and long-lasting results despite high revision rates. Refined techniques to decrease the revision rates are needed in the future.

The Concept of an Ideal Lips of Caucasian Male: An Anthropometric Analysis of the Lower Third of the Face

BACKGROUND

The lips play a significant role in determining the aesthetic perception of a human face. However, there is little data on the perioral region morphometry of attractive males.

OBJECTIVES

This study investigates the morphology of the lower third of the face, including the lips and jawline, of attractive young Caucasian males.

METHODS

A complex semi-automatic photogrammetric analysis of faces of male photo models (n=300) of the Caucasian race, aged 18-39 years old, was performed. Linear, angular, and surface area parameters were evaluated. In addition, an Average Body Contours (ABC) image was created, providing the graphical summarization of facial size and shapes of all analyzed individuals.

RESULTS

The height of the lower third of the face equaled 0.35 ± 0.03 of the total facial height. The average lip width was 50.98 ± 3.74 mm. The upper vermilion height was found significantly lower than the lower vermilion height (5.9 ± 1.62 vs. 11.15 ± 1.88 mm, p<0.01). The lip obliquity angle was found to be 1.01 o ± 0.73 o. The area surface of the lower lip vermilion was considerably larger than the vermilion of the upper lip (p<0.01).

CONCLUSIONS

The vast amount of morphometric data, including the novel presentation method as an ABC image, on the attractive male's lower third of the face, may provide the surgeons with practical guidelines for lips surgical and nonsurgical rejuvenation procedures. It may also support the perioral region reconstruction and sex reassignment surgery in achieving satisfactory results.

Multiple Model Evaluation of the Masseteric-to-Facial Nerve Transfer for Reanimation of the Paralyzed Face and Quick Prognostic Prediction

Facial paralysis is negatively associated with functional, aesthetic, and psychosocial consequences. The masseteric-to-facial nerve transfer (MFNT) has many advantages in facial reanimation. The aim is to evaluate the effectiveness of our MFNT technique and define the potential factors predictive of outcome. The authors conducted a retrospective review of 20 consecutive patients who underwent MFNT using the temporofacial trunk of facial nerve. Videotapes and images were documented and evaluated according to Facial Nerve Grading Scale 2.0 (FNGS2.0) and Sunnybrook Facial Grading System (FGS). The quality-of-life was obtained using the Facial Clinimetric Evaluation (FaCE) Scale. Moreover, Facial Asymmetry Index (FAI), quantitative measurement of the width of palpebral fissure, deviation of the philtrum, and angles or excursions of the oral commissure were applied to explore the effect of the transfer metrically. Multivariable logistic regression models and Cox regression were prepared to predict the effect of MFNT by preoperative clinical features. The patients showed favorable outcomes graded by FNGS2.0, and experienced significantly improved scores in static and dynamic symmetry with slightly elevated scores in synkinesis evaluated by the Sunnybrook FGS. The score of FaCE Scale increased in all domains after reanimation. The quantitative indices indicated the symmetry restoration of the middle and lower face after MFNT. Regression analysis revealed that younger patients with severe facial paralysis are preferable to receive MFNT early for faster and better recovery, especially for traumatic causes. The findings demonstrate that MFNT is an effective technique for facial reanimation, and case screening based on clinical characteristics could be useful for surgical recommendation.

Dynamic Reconstruction of Facial Paralysis in Craniofacial Macrosomia

BACKGROUND

Craniofacial microsomia is associated with maxillomandibular hypoplasia, microtia, soft-tissue deficiency, and variable severity of cranial nerve dysfunction, most often of the facial nerve. This study evaluated the incidence of patients with craniofacial microsomia and facial paralysis and their outcomes after free functioning muscle transfer for dynamic smile reconstruction.

METHODS

A single-center, retrospective, cross-sectional study was performed from 1985 to 2018 to identify pediatric patients with craniofacial microsomia and severe facial nerve dysfunction who underwent dynamic smile reconstruction with free functioning muscle transfer. Preoperative and postoperative facial symmetry and oral commissure excursion during maximal smile were measured using photogrammetric facial analysis software.

RESULTS

This study included 186 patients with craniofacial microsomia; 41 patients (21 male patients, 20 female patients) had documented facial nerve dysfunction (22 percent), affecting all branches (51 percent) or the mandibular branch only (24 percent). Patients with severe facial paralysis (n = 8) underwent midfacial (i.e., smile) reconstruction with a free functioning muscle transfer neurotized either with a cross-face nerve graft (n = 7) or with the ipsilateral motor nerve to masseter (n =1). All patients achieved volitional muscle contraction with improvement in symmetry and oral commissure excursion (median, 8 mm; interquartile range, 3 to 10 mm). The timing of orthognathic surgery and facial paralysis reconstruction was an important consideration in optimizing patient outcomes.

CONCLUSIONS

The authors' institution's incidence of facial nerve dysfunction in children with craniofacial microsomia is 22 percent. Free functioning muscle transfer is a reliable option for smile reconstruction in children with craniofacial microsomia. To optimize outcomes, a novel treatment algorithm is proposed for craniofacial microsomia patients likely to require both orthognathic surgery and facial paralysis reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Comparative Study of Autologous and Acellular Dermal Matrix Static Cheek Slings in Corrective Surgery for Facial Palsy

BACKGROUND

Facial palsy causes devastating disability due to loss of facial function as well as social and psychological impairment. Cheek slings are a secondary technique that provide static support to the midface. This study aimed to describe our technique and compare a traditional sling material (tensor fascia lata) with a porcine-derived acellular dermal matrix alternative (Strattice).

METHODS

A 5-year case-control retrospective review of consecutive static cheek slings in a tertiary cancer and facial palsy center was performed. Demographic data, risk factors, and complications were collected and compared. Improvement in static smile position was assessed by Emotrics (Massachusetts Eye and Ear Infirmary, Boston, MA) at 3 months. Long-term sling failure was assessed by need for reoperation.

RESULTS

The study group comprised 41 patients on which 33 autogenous fascia lata slings and 12 Strattice slings were performed. Medium-term improvement in static smile position was similar between the 2 groups (judged by the Emotrics software), as was complication rate (P = 0.496). Need for revision due to stretching was higher in the Strattice group but did not achieve significance (P = 0.087). Mean follow-up was 38.02 ± 19.17 months. Twelve of 41 patients were deceased at study conclusion.

CONCLUSIONS

Fascia lata and Strattice slings provide satisfactory results in restoring symmetry at rest and functional oral competence. Our results suggest that Strattice is a safe sling material with an acceptable risk profile and comparable medium-term maintenance of tensile strength to fascia lata, and should be considered where life expectancy, donor site morbidity, and procedure length are important considerations.

Toward an Automatic System for Computer-Aided Assessment in Facial Palsy

Importance: Quantitative assessment of facial function is challenging, and subjective grading scales such as House-Brackmann, Sunnybrook, and eFACE have well-recognized limitations. Machine learning (ML) approaches to facial landmark localization carry great clinical potential as they enable high-throughput automated quantification of relevant facial metrics from photographs and videos. However, the translation from research settings to clinical application still requires important improvements. Objective: To develop a novel ML algorithm for fast and accurate localization of facial landmarks in photographs of facial palsy patients and utilize this technology as part of an automated computer-aided diagnosis system. Design, Setting, and Participants: Portrait photographs of 8 expressions obtained from 200 facial palsy patients and 10 healthy participants were manually annotated by localizing 68 facial landmarks in each photograph and by 3 trained clinicians using a custom graphical user interface. A novel ML model for automated facial landmark localization was trained using this disease-specific database. Algorithm accuracy was compared with manual markings and the output of a model trained using a larger database consisting only of healthy subjects. Main Outcomes and Measurements: Root mean square error normalized by the interocular distance (NRMSE) of facial landmark localization between prediction of ML algorithm and manually localized landmarks. Results: Publicly available algorithms for facial landmark localization provide poor localization accuracy when applied to photographs of patients compared with photographs of healthy controls (NRMSE, 8.56 ± 2.16 vs. 7.09 ± 2.34, p ≪ 0.01). We found significant improvement in facial landmark localization accuracy for the facial palsy patient population when using a model trained with a relatively small number photographs (1440) of patients compared with a model trained using several thousand more images of healthy faces (NRMSE, 6.03 ± 2.43 vs. 8.56 ± 2.16, p ≪ 0.01). Conclusions and Relevance: Retraining a computer vision facial landmark detection model with fewer than 1600 annotated images of patients significantly improved landmark detection performance in frontal view photographs of this population. The new annotated database and facial landmark localization model represent the first steps toward an automatic system for computer-aided assessment in facial palsy. Level of Evidence: 4.

Transposition of the Intratemporal Facial to Hypoglossal Nerve for Reanimation of the Paralyzed Face: The VII to XII TranspositionTechnique

IMPORTANCE

The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation.

OBJECTIVES

To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation.

DESIGN, SETTINGS, AND PARTICIPANTS

A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center.

MAIN OUTCOMES AND MEASURES

Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis.

METHODS

Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system.

RESULTS

All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction.

CONCLUSIONS AND RELEVENCE

Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites.

LEVEL OF EVIDENCE

4.

Facial reanimation of patients with neurofibromatosis type 2

BACKGROUND

Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome defined by bilateral vestibular schwannomas. Facial paralysis, from either tumor growth or surgical intervention, is a devastating complication of this disorder and can contribute to disfigurement and corneal keratopathy. Historically, physicians have not attempted to treat facial paralysis in these patients.

OBJECTIVE

To review our clinical experience with free gracilis muscle transfer for the purpose of facial reanimation in patients with NF2.

METHODS

Five patients with NF2 and complete unilateral facial paralysis were referred to the facial nerve center at our institution. Charts and operative reports were reviewed; treatment details and functional outcomes are reported.

RESULTS

Patients were treated between 2006 and 2009. Three patients were men and 2 were women. The age of presentation of debilitating facial paralysis ranged from 12 to 50 years. All patients were treated with a single-stage free gracilis muscle transfer for smile reanimation. Each obturator nerve of the gracilis was coapted to the masseteric branch of the trigeminal nerve. Measurement of oral commissure excursions at rest and with smile preoperatively and postoperatively revealed an improved and nearly symmetric smile in all cases.

CONCLUSION

Management of facial paralysis is often times overlooked when defining a care plan for NF2 patients who typically have multiple brain and spine tumors. The paralyzed smile may be treated successfully with single-stage free gracilis muscle transfer in the motivated patient.

Surgical site infections after gracilis free flap reconstruction for facial paralysis

Compared with other free tissue transfer procedures, the gracilis free muscle transfer (GFMT) for facial reanimation is unique in that the recipient site is typically uninvolved by malignancy or infection. In this study, the authors examined the incidence, bacteriology, and outcomes of surgical site infection (SSI) after gracilis free muscle transfer for facial reanimation. From 2003 to 2011, 105 patients underwent 107 GFMT operations, with 6 SSIs. All cases of infection occurred in patients receiving clindamycin, levofloxacin, and/or cefazolin perioperatively. None of the patients who received ampicillin-sulbactam developed an SSI. Surgical site cultures grew oral flora, including α-hemolytic streptococci, Haemophilus parainfluenzae, Fusobacterium and Neisseria species, and coagulase-negative staphylococci. Notably, there were no methicillin-resistant Staphylococcus aureus (MRSA) infections. These data may have implications for the optimal perioperative antibiotic choice in facial reanimation cases. Further study is needed to determine the ideal antibiotic regimen for this category of free flap surgeries.