Controversies in Contemporary Facial Reanimation

Masseteric-facial anastomosis and hypoglossal-facial anastomosis after lateral skull base and middle ear surgery

INTRODUCTION

Lateral skull base (LSB) and middle ear pathologies often involve the facial nerve (FN), and their treatment may require FN sacrifice. Cases with unidentifiable proximal stump or intact FN with complete FN palsy, necessitate FN anastomosis with another motor nerve in order to restore innervation to the mimicking musculature. The results of hypoglossal-to-facial nerve anastomosis (HFA) and masseteric-facial nerve anastomosis in patients with facial paralysis after middle ear and LSB surgeries, are presented and compared.

METHODS

Adult patients with total definitive facial paralysis after middle ear or LSB surgery undergoing facial nerve reanimation through hypoglossal or masseteric transfer anastomosis were enrolled. The facial nerve function was graded according to the House Brackmann grading system (HB). The facial function results at 3 months, 6 months, 12 months, 18 months and at the last follow up (more than 18 months) are compared.

RESULTS

153 cases of LSB and middle ear surgery presented postoperative facial palsy and underwent facial nerve reanimation surgery with HF in 85 patients (55.5%) and MF in 68 patients (44.5%). The duration of the FN palsy before reconstructive surgery was inversely associated to better FN results, in particular with having a grade III HB (p = 0.003). Both techniques had significantly lower HB scores when an interval between palsy onset and reanimation surgery was 6 months or less (MF p = 0.0401; HF p = 0.0022). Patients who underwent a MF presented significant improvement of the FN function at 3 months from surgery (p = 0.0078). At the last follow-up, 63.6% recovered to a grade III HB and 22.7% to a grade IV. On the other hand, the first significant results obtained in the HF group were at 6 months from surgery (p < 0.0001). 67.8% of patients had a grade III HB after a HF at the last follow-up, 28.8% a grade IV. FN grading at 6 months from surgery was significantly lower in the MF group compared to the HF (p = 0.0351). The two techniques had statistically similar results at later follow-up evaluations.

DISCUSSION/CONCLUTION

MF was associated to initial superior results, presenting significant facial recovery at 3 months, and significantly better functional outcomes at 6 months from surgery compared to HF. Although later results were not significantly different in this study, earlier results have an important role in order to limit the duration of risk of corneal exposure.

Longitudinal Analysis of the Use of Facial Reanimation Procedures for Bell's Palsy

Background: Treatment of Bell's palsy ranges from medical management with high-dose corticosteroids to complex facial reanimation procedures. Objective: To characterize the number of static, dynamic, and combined facial reanimation procedures for the management of Bell's palsy using a national database over time. Methods: This retrospective cohort study included patients in the 2013-2020 National Surgical Quality Improvement Project database with a postoperative diagnosis of Bell's palsy. Cases were categorized as involving only static, only dynamic, and a combination of static and dynamic procedures. Chi-square or Fisher's exact tests were performed for patient demographics, and linear regressions were created to evaluate utilization trends. Results: In total, 294 patients were identified. There was no significant difference in patient sex and comorbidities between these treatment groups. Of the 294 patients, 101 received both types of procedures, 107 received only dynamic procedures, and 86 received only static procedures. The trendlines for all treatment groups were significantly positive (B = 1.27 for both, B = 0.89 for dynamic only, and B = 1.01 for static only). Conclusion: In this study of a national surgical database, an increase in static, dynamic, and combined treatments for patients with Bell's palsy was found.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

A Novel Approach to Facial Reanimation and Restoration Following Radical Parotidectomies

Background: Parotidectomies are indicated for a variety of reasons. Regardless of the indication for surgery, facial reanimation may be required because of facial nerve sacrifice or iatrogenic damage. In these cases, facial restoration performed concurrently with ablative surgery is considered the gold standard, and delayed reanimation is usually not attempted. Methods: A retrospective review of all patients who underwent parotidectomies from 2009 to 2022 in a single institution was performed. Indications, surgical techniques, and outcomes of an algorithmic template were applied to these cases using the Sunnybrook, Terzis scores, and Smile Index. A comparison was made between immediate vs. late repairs. Results: Of a total of 90 patients who underwent parotidectomy, 17 (15.3%) had a radical parotidectomy, and 73 (84.7%) had a total or superficial parotidectomy. Among those who underwent complete removal of the gland and nerve sacrifice, eight patients (47.1%) had facial restoration. There were four patients each in the immediate (n = 4) and late repair (n = 4) groups. Surgical techniques ranged from cable grafts to vascularized cross facial nerve grafts (sural communicating nerve flap as per the Koshima procedure) and vascularized nerve flaps (chimeric vastus lateralis and anterolateral thigh flaps, and superficial circumflex perforator flap with lateral femoral cutaneous nerve). Conclusions: The algorithm between one technique and another should take into consideration age, comorbidities, soft tissue defects, presence of facial nerve branches for reinnervation, and donor site morbidity. While immediate facial nerve repair is ideal, there is still benefit in performing a delayed repair in this algorithm.

Pediatric Facial Reanimation

Pediatric facial palsy is rare but severely debilitating and results in profound functional, developmental, psychosocial, and esthetic consequences. Identifying the specific cause of the palsy is important in directing the treatment course. The most common etiologies of pediatric facial palsy are distinct from those of adults. Facial reanimation interventions are targeted to address the zones of the face, with oral/smile rehabilitation the most common region requiring intervention in pediatric patients. Gracilis microneurovascular free tissue transfer is safe and highly effective in the pediatric population, providing significant functional, psychosocial, and esthetic benefits.

The Ansa Hypoglossi: Quantifying Axonal Density of a Donor Nerve for Facial Reinnervation

Background: There are a number of nerve grafting options for facial reanimation and the ansa hypoglossi (AH) may be considered in select situations. Objective: To compare axonal density, area, and diameter of AH with other nerves more usually used for facial reanimation. Methods: AH specimens from patients undergoing neck dissections were submitted in formalin. Proximal to distal cross sections, nerve diameters, and the number of axons per nerve, proximally and distally, were measured and counted. Results: Eighteen nerve specimens were analyzed. The average manual axon count for the distal and proximal nerve sections was 1378 ± 333 and 1506 ± 306, respectively. The average QuPath counts for the proximal and distal nerve sections were 1381 ± 325 and 1470 ± 334, respectively. The mean nerve area of the proximal and distal nerve sections was 0.206 ± 0.01 and 0.22 ± 0.064 mm2, respectively. The mean nerve diameter for the proximal and distal nerve sections were 0.498 ± 0.121 and 0.526 ± 0.75 mm, respectively. Conclusion: The histological characteristics of the AH support clinical examination of outcomes as a promising option in facial reanimation.

Management, Referral Patterns, and Outcomes in Bell's Palsy: A Single-Institution 903 Patient Series

OBJECTIVE

In 2013, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published guidelines for Bell's palsy (BP), including recommendations for workup, management, and specialist referral. Patients with BP often present to primary care; however, adherence to guidelines may vary by setting. This study sought to evaluate the management of patients with BP presenting to primary care, emergency department (ED), and urgent care settings.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

METHODS

Retrospective chart review of patients identified by diagnosis code for BP.

RESULTS

A total of 903 patients were included; 687 (76.1%) presented to ED, 87 (9.6%) to internal medicine, 77 (8.5%) to family medicine, and 52 (5.8%) to urgent care. On presentation, 804 (89.0%) patients were prescribed corticosteroids and 592 (65.6%) antiviral therapy. Steroid therapy ranged from 1 dose to greater than a 14-day course, with 177 (19.6%) receiving an adequate duration of 10 days or greater. Referrals were provided to facial plastics and/or otolaryngology for 51 patients (5.6%). For all comers, 283 (31.3%) had complete resolution, 197 (21.8%) had an incomplete resolution, 62 (6.9%) had persistent palsy, and 361 (40.0%) lost to follow-up. In assessing the association between clinic setting and management, appropriate corticosteroid therapy (p < .01), imaging (p < .01), and eye care (p < .01) were statistically significant.

CONCLUSION

Adherence to guidelines for BP management varies amongst providers. In our study cohort, 15.5% of patients received medical therapy in accordance with AAO-HNS guidelines, and only 5.6% were referred to facial plastics. To facilitate more appropriate care, tertiary care institutions may benefit from system-wide care pathways to manage acute BP.

Dynamic eyelid reconstruction in facial nerve palsy

The consequences of facial nerve palsy and the secondary inability of eyelid closure and blink may lead to devastating complications for the patient, including blindness. Reconstruction techniques to improve eyelid position and function can be broadly classified into 'static' and 'dynamic' techniques. Generally, ophthalmologists have been familiar with static procedures such as upper eyelid loading, tarsorrhaphy, canthoplasty, and lower eyelid suspension. Recently, dynamic techniques are being increasingly described for patients who require definitive strategies to improve eyelid function, once the initial critical goals of corneal protection and vision preservation have been achieved. The choice of technique(s) is dependent upon the status of the main protractor of the eyelid region, as well as the age of the patient, the patient's morbidities and expectations, and surgeon preference. This review shall first describe the clinical and surgical anatomy relevant to the ophthalmic consequences of facial paralysis and discuss methods of defining function and outcomes. A comprehensive review of dynamic eyelid reconstruction is then presented with a discussion of the literature. These various techniques may not be familiar to all clinicians. It is important that ophthalmic surgeons are aware of all options available for their patients. Furthermore, eye care providers must have an understanding of when referral may be appropriate to provide timely intervention and optimal chances of recovery.

Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer

Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82 mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49 mm; the average difference in the commissure height deviation was 2.26 mm (P = 0.02), and those in the upper- and lower-lip height deviation were 1.05 mm and 1.49 mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.

The evolution of facial reanimation techniques

This review article provides an updated discussion on evidence-based practices related to the evaluation and management of facial paralysis. Ultimately, the goals of facial reanimation include obtaining facial symmetry at rest, providing corneal protection, restoring smile symmetry and facial movement for functional and aesthetic purposes. The treatment of facial nerve injury is highly individualized, especially given the wide heterogeneity regarding the degree of initial neuronal insult and eventual functional outcome. Recent advancements in facial reanimation techniques have better equipped clinicians to approach challenging patient scenarios with reliable, effective strategies. We discuss how technology such as machine learning software has revolutionized pre- and post-intervention assessments and provide an overview of current controversies including timing of intervention, choice of donor nerve, and management of nonflaccid facial palsy with synkinesis. We highlight novel considerations to mainstay conservative management strategies and examine innovations in modern surgical techniques with a focus on gracilis free muscle transfer. Innervation sources, procedural staging, coaptation patterns, and multi-vector and multi-muscle paddle design are modifications that have significantly evolved over the past decade.

Reducing Risk in Facial Reanimation Surgery

Facial reanimation surgery can greatly improve quality of life, but these procedures are not without risk. Important considerations for risk reduction in facial reanimation surgery include preoperative risk-stratification, protecting patients' clinical media, clearly and thoroughly setting expectations, and intraoperative strategies to maximize technical success and minimize operative time.

Trends in Facial Paralysis Management: A National Survey Study

INTRODUCTION

Advances in operative management, minimally invasive procedures, and physical therapy have allowed for dramatic improvements in functional and cosmetic outcomes in patients with facial paralysis. Our goal was to evaluate the current trends and practice patterns in the diagnosis and management of facial paralysis by provider demographics.

MATERIALS AND METHODS

An electronic questionnaire was distributed to members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Practice patterns in the diagnosis and treatment were compared by level of training (fellowship-trained facial plastic and reconstructive surgeon versus non-fellowship trained), practice type (academic and private), practice length, patient volume, and presence of a dedicated facial nerve clinic. The bivariate associations of the outcome variables and the stratification factors were analyzed using 2-way contingency tables and Fisher's exact tests.

RESULTS

The survey was sent to 1129 members of the AAFPRS. The response rate was 11.7% (n=132). Most respondents were fellowship-trained surgeons (79%) in the academic setting (55%), and most have been in practice for more than 10 years (53%). Practice setting and patient volume were the factors most associated with significant variations in management, including the use of facial paralysis grading scales, photography/videography, patient-reported outcome metrics, as well as differences in both noninvasive and surgical management.

CONCLUSION

Based on the present study, several physician demographic factors may play a role in choosing which diagnostic and treatment options are employed for facial paralysis, with practice setting and patient volume appearing to be the 2 variables associated with the most significant differences.

Seminal Studies in Facial Reanimation Surgery: Consensus and Controversies in the Top 50 Most Cited Articles

ABSTRACT

Facial paralysis can impair one's ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist.Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.

Two-Stage Dual-Nerve Facial Reanimation: Outcomes and Complications in a Series of Pediatric Patients

Background

In facial reanimation via microneurovascular muscle transfer, dual-nerve reinnervation of the muscle capitalizes on the synergistic effects of spontaneous motion from cross facial nerve grafting (CFNG) and increased excursion from masseteric nerve transfer. Two-stage approaches that delay masseteric nerve transfer until the time of the muscle flap increase spontaneity by maximizing muscle reinnervation from the CFNG. While this 2-stage, dual-nerve approach has been described in adults, we present a series of pediatric patients who underwent this reconstructive technique.

Methods

We retrospectively reviewed all pediatric patients who underwent 2-stage, dual-nerve reconstruction with CFNG and ipsilateral masseteric nerve transfers. Procedures were performed between 2004 and 2016 by 2 surgeons at a single centre. Degree of facial paralysis before and after surgical intervention was measured using House-Brackmann scores.

Results

Nine patients with a mean age of 8.6 (range: 5-15 years) years at time of surgery underwent 2-stage, dual-nerve reconstruction. Average time between CFNG and transfer of the free gracilis with masseteric nerve transfer was 13.3 (SD 2.4) months. Mean follow-up was 27.3 months (SD 25.7). Patients demonstrated initiation of voluntary movement on paralyzed side by 3.6 months (SD 0.6) on average, with 3 patients demonstrating spontaneous movement at 3 months.

Conclusion

The 2-stage, dual innervation technique using CFNG and delayed ipsilateral masseteric nerve transfer with a free gracilis is a promising reconstructive option to maximize spontaneous expression in pediatric patients. Validated, objective scoring systems for excursion are needed before meaningful comparisons can be made to other reconstructive strategies.

Smile Outcomes of an Externally Scarless, Intraoral Orthodromic Temporalis Tendon Transfer

Background: Temporalis tendon transfer (TTT) often relies on external incisions in the nasolabial fold, temporal region, or both. Herein, we studied smile outcomes of a TTT technique via a single intraoral incision without external skin incisions. Objective: To measure the difference in static perioral positions before and after intraoral TTT. Methods: Five patients underwent an externally scarless TTT technique via an intraoral approach. Iris measurements were used to estimate pixel-to-millimeter conversion for facial analysis of vertical and horizontal oral commissure excursion vectors using the JAVA-based program Facegram version 1.0 (Massachusetts Eye & Ear Infirmary). Results: After surgery, mean vertical height on the affected side significantly increased from 3.4 mm to a postoperative value of 20.6 mm, p = 0.016. There was no difference in horizontal smile excursion after surgery (35.7 mm vs. 32.2 mm, p = 0.37). Smile angle difference between affected and healthy smile (Δα) reduced from 27.0° preoperative to 3.5°, representing a decrease in facial asymmetry (p = 0.002). Conclusion: Intraoral, externally scarless TTT is an effective option for dynamic facial reanimation, obviating external incisions in select patients.

The Experience of a Facial Nerve Unit in the Treatment of Patients With Facial Paralysis Following Skull Base Surgery

: The management of facial paralysis following skull base surgery is complex and requires multidisciplinary intervention. This review shows the experience of a facial nerve (FN) unit in a tertiary university referral center. A multidisciplinary approach has led to the breaking of some old treatment paradigms. An overview of five FN scenarios is presented. For each setting a contemporary approach is proposed in contrast to the established approach. 1) For patients with an anatomically preserved FN with no electrical response at the end of surgery for vestibular schwannoma, watchful waiting is usually advocated. In these cases, reinforcement with an interposed nerve graft is recommended. 2) In cases of epineural FN repair, with or without grafting, and a poor expected prognosis, an additional masseter-to-facial transfer is recommended. 3) FN transfer, mainly hypoglossal-to-facial and masseter-to facial, are usually chosen based on the surgeons' preference. The choice should be based on clinical factors. A combination of techniques improves the outcome in selected patients. 4) FN reconstruction following malignant tumors requires a combination of parotid and temporal bone surgery, involving different specialists. This collaboration is not always consistent. Exposure of the mastoid FN is recommended for lesions involving the stylomastoid foramen, as well as intraoperative FN reconstruction. 5) In patients with incomplete facial paralysis and a skull base tumor requiring additional surgery, consider an alternative reinnervation procedure, "take the FN out of the equation" before tumor resection. In summary, to achieve the best results in complex cases of facial paralysis, a multidisciplinary approach is recommended.

A New Neurorehabilitative Postsurgery Intervention for Facial Palsy Based on Smile Observation and Hand-Mouth Motor Synergies

Objective

To perform a preliminary test of a new rehabilitation treatment (FIT-SAT), based on mirror mechanisms, for gracile muscles after smile surgery.

Method

A pre- and postsurgery longitudinal design was adopted to study the efficacy of FIT-SAT. Four patients with bilateral facial nerve paralysis (Moebius syndrome) were included. They underwent two surgeries with free muscle transfers, one year apart from each other. The side of the face first operated on was rehabilitated with the traditional treatment, while the second side was rehabilitated with FIT-SAT. The FIT-SAT treatment includes video clips of an actor performing a unilateral or a bilateral smile to be imitated (FIT condition). In addition to this, while smiling, the participants close their hand in order to exploit the overlapped cortical motor representation of the hand and the mouth, which may facilitate the synergistic activity of the two effectors during the early phases of recruitment of the transplanted muscles (SAT). The treatment was also aimed at avoiding undesired movements such as teeth grinding. Discussion. Results support FIT-SAT as a viable alternative for smile rehabilitation after free muscle transfer. We propose that the treatment potentiates the effect of smile observation by activating the same neural structures responsible for the execution of the smile and therefore by facilitating its production. Closing of the hand induces cortical recruitment of hand motor neurons, recruiting the transplanted muscles, and reducing the risk of associating other unwanted movements such as teeth clenching to the smile movements.

Facial Animation With Free Functional Gracilis Transfer Innervated by the Cross-Facial Nerve Graft

BACKGROUND

The treatment of long-standing facial paralysis has always been a challenge for plastic surgery. The purpose of this study was to demonstrate that the free functional gracilis transfer innervated by the cross-facial nerve graft (CFNG) is still an ideal option, even though there are many new surgical options available.

METHODS

A retrospective survey was made on 12 patients who received free functional gracilis transfer innervated by the CFNG. A modified version of the House-Brackmann scale was used to evaluate the movement of the corners of mouth after surgery. Patients were also asked about their satisfaction with the operation. In addition, an objective test was performed to assess the postoperative angle improvement by measuring the angle formed between the horizontal line of both corners of the lips and the vertical midline.

RESULTS

All grafts survived well. No severe complication occurred. Three patients received further surgical operations for aesthetic reasons. The movement of the corners of mouth was classified as excellent in 8 cases, good in three cases, and fair in one cases. The static angle and dynamic angle of postoperation improved and the range of dynamic angle improvement was larger than that of static angle.

CONCLUSION

Free functional gracilis transfer innervated by the CFNG is an ideal technique for facial paralysis. It can effectively improve the facial dynamic of the affected side.

Comparative analysis of the nerve transfer methodologies used during surgical treatment of peripheral facial paresis

Introduction. When considering the array of biomedical problems associated with facial nerve palsy (FNP), it is apparent that the problem of choosing an effective type of facial nerve transfer is of paramount relevance. Hence, it is to the pursuit of a solution to the above stated problem that our study is devoted.

Materials and methods. We analyzed the data obtained as a result of assessing the outcome of 149 patients with trauma-caused FNP who had undergone surgical treatments in the period between 2001-2018. The FN nerve transfer techniques utilized were as such: for group 1 – the use as a donor nerve the branch of the accessory nerve innervating the sternocleidomastoid muscle (n=87); group 2 – the descending branch of the hypoglossal and the branch of the accessory nerve (n=62).

Results. In groups 1–2, the FN nerve transfer significantly improved FN function (p <0.01; Wilcoxon Matched Pairs Test), and most patients (n=135; 90.6%) noted an improvement in the clinical status up to degree II-III on the House-Brackmann scale (good result).

Conclusion. The use of the accessory nerve branches to the sternocleidomastoid muscle, as donated, ensures restoration of FN function to levels II-III on the House-Brackmann scale in 89.7% of all operated patients, and the results it achieves do not differ from those of the technically more complex nerve transfer of FN by descending branch of the hypoglossal nerve with combination of branches of the accessory nerve.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

Advances in facial nerve management in the head and neck cancer patient

PURPOSE OF REVIEW

The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery.

RECENT FINDINGS

Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes.

SUMMARY

Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.

Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile

Importance

Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive.

Objective

To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile.

Design, Setting, and Participants

In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified.

Intervention

Masseteric-to-facial nerve transfer.

Main Outcomes and Measures

Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side).

Results

Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant.

Conclusion and Relevance

This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality.

Level of Evidence

4.

Dual Coaptation of Facial Nerve Using Masseteric Branch of Trigeminal Nerve for Iatrogenic Facial Palsy: Preliminary Reports

OBJECTIVES

Immediate facial nerve substitution or graft technique has been used for the repair of facial nerve defects occurring as a result of tumour dissection. However, some patients report unsatisfactory outcomes, such as difficulty in maintaining resting or smiling symmetry, due to persistent flaccid facial palsy. Here we evaluated the functional outcomes of transferring the masseteric branch of the trigeminal nerve to the facial nerve adjunct to facial nerve graft.

METHODS

We reviewed the medical records of seven patients who underwent facial reanimation surgery between 2014 and 2016. The patients were divided into two groups according to the type of facial reanimation surgery: group A, masseteric nerve innervation with interposition graft; group B, interposition graft only. The postoperative resting symmetry and dynamic movement were compared.

RESULTS

Facial contraction was first observed in group A at 4 months and in group B at 7.3 months. Most of the patients achieved reliable resting symmetry; however, one patient in group B exhibited unsatisfactory facial weakness on the affected side. Group A patients showed better dynamic movement than group B patients. Eye closure, oral excursion and oral continence were better in group A than in group B patients. Smile symmetry in both groups was similar due to hyperkinetic movement in group A patients and flaccidity in group B patients.

CONCLUSIONS

Dual innervation of the masseteric branch of the trigeminal nerve improves the dynamic movement of paralysed facial muscles and shortens the recovery period in patients with iatrogenic facial palsy.

Comparison of Objective Outcomes in Dynamic Lower Facial Reanimation With Temporalis Tendon and Gracilis Free Muscle Transfer

Importance

Facial paralysis affects patients' physical, social, and psychological function. Dynamic smile reanimation can mitigate these effects, but there are limited data to guide the surgeon in selecting the best reanimation procedure for each patient.

Objective

To compare quantitative changes in oral commissure symmetry and smile excursion following temporalis tendon transfer (T3) and gracilis free muscle transfer.

Design, Setting, and Participants

Retrospective case series of 28 adults with unilateral facial paralysis seeking dynamic lower facial reanimation at a tertiary academic medical center between July 1, 2010, and July 30, 2014. Data were analyzed from May 1, 2016, to June 30, 2016.

Interventions

Minimally invasive T3 (n = 14) compared with gracilis free muscle transfer (n = 14).

Main Outcomes and Measures

Measured symmetry of the oral commissure between the healthy and paralyzed sides in the horizontal, vertical, and angular dimension and excursion of the paralyzed commissure following reanimation compared with the healthy commissure.

Results

Of the 28 patients, 19 (68%) were women; mean (SD) age was 51.7 (17) years. Commissure symmetry during smile improved significantly for the T3 patients in the vertical and angular dimensions, and the gracilis free muscle transfer patients had significant improvement in the vertical and horizontal dimensions. Commissure excursion significantly improved in both groups following surgery, with a larger improvement seen in the gracilis free muscle transfer group (11.3 mm; 95% CI, 7.0 to 15.5 mm) compared with the T3 group (4.8 mm; 95% CI, 0.2 to 9.3 mm), with a mean difference of 6.5 mm (95% CI, 0.7 to 12.4 mm; Cohen d, 0.86). Postoperative smile excursion of the paralyzed side was within 1.0 mm of the healthy side in the gracilis free muscle transfer group (95% CI, -2.1 to 4.0 mm).

Conclusions and Relevance

Temporalis tendon transfer and gracilis free muscle transfer both improve oral commissure symmetry and excursion in facial paralysis. The improvement in smile excursion appears to be larger in patients treated with gracilis free muscle transfer and, on average, the excursion approximates the contralateral healthy side.

Temporalis Muscle Transfer with Fascia Lata Sling: A Novel Technique for Facial Reanimation

Bell's palsy is an idiopathic facial paralysis which is a lower motor neuron disorder. The ultimate goal of treatment is normalization of paralyzed hemi -face with symmetrical smile and face along with corneal protection. The aim of this article is to revisit all the current options available for management of facial nerve paralysis with main concentration on best surgical management in long-standing cases i.e. regional muscle transfer using temporalis tendon with fascia lata. A Case Report of a 38 year old Indian male is reported with chronic facial palsy. Static Facial paralysis reanimation with fascia lata and tarsorrhaphy is explained step by step. Others Treatment modalities are explained. This present case report adds one more case to the scanty number of publications.

Early Masseter to Facial Nerve Transfer May Improve Smile Excursion in Facial Paralysis

Supplemental Digital Content is available in the text.

Background:

Masseter-to-facial nerve transfer has been shown to be an effective and safe treatment option in patients with acute and subacute facial palsy. The present article aims to characterize whether there is a benefit in early nerve transfers while minimizing other confounding variables; we present a study that consist of only patients with complete facial nerve paralysis resulting from intratemporal facial nerve resections.

Methods:

Between 2012 and 2016, 7 masseter-to-facial nerve transfers were performed for complete facial nerve palsy after intratemporal proximal nerve resections. Pre- and postoperative photographic and video evaluations were performed using both the Sunnybrook facial grading scale and the MEEI FACE-gram software for more objective metric measurements. Statistical analysis was performed to determine which patient and surgical variables had significant effects on outcome.

Results:

Mean 14-month follow-up revealed that patients who underwent nerve transfer prior to 6 months’ denervation achieved postoperative oral commissural excursion of 11.1 mm versus 6.5 mm in patients who underwent nerve transfer after 6 months (P = 0.003). Performing masseter-to-facial nerve transfer to the main facial nerve trunk resulted in a significantly higher improvement in the modiolus-philtral ratio (31.6% versus 6.1%) than selective transfer in patients (P = 0.01) at the latest follow-up.

Conclusions:

Early masseter-to-facial nerve transfers, before 6 months of palsy duration, can potentially improve smile excursion and symmetry of open mouth smile. Additionally, truncal coaptations may provide improved tone over coapting to selective facial nerve branches. These findings necessitate larger studies regarding the importance of denervation time with fifth-to-seventh nerve transfers.