Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: A literature review

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.

A Combined Approach of Facial Neuromuscular Rehabilitation and Surgical Reconstruction in the Remediation of Facial Palsy: A Multidisciplinary Team Approach

Facial neuromuscular rehabilitation (fNMR) is an evidence-based practice for the treatment of peripheral facial palsy (PFP). Surgical reconstruction can be indicated for patients who demonstrate poor or no recovery to support symmetry, function, and aesthesis. There is paucity of research demonstrating the therapeutic benefit of a multidisciplinary team (MDT) in facial recovery of this specific subpopulation of patients. This article will outline the role of specialist facial therapy in the remediation of PFP, focusing on those who undergo surgical reconstruction to optimize their facial recovery. Case studies are used to demonstrate surgical and therapeutic outcomes as well as the results of a patient survey conducted for a service evaluation. We discuss the role of the MDT in supporting recovery as well as the role of targeted fNMR. The term fNMR is often used interchangeably with facial therapy or facial rehabilitation. We will refer to fNMR as a technique of facial rehabilitation.We aim to demonstrate that an MDT approach to the treatment of people with facial palsy provides positive outcomes for this surgical population and that future research would be beneficial to support this service delivery model.

Quantitative analysis of facial symmetry and animation following intraoral orthodromic temporalis transfer in facial paralysis

This study aimed to quantitatively analyze the degree and vector of commissure excursion following intraoral orthodromic temporalis transfer. Patients with unilateral facial paralysis who underwent intraoral temporalis transfer were included. Intra-oral coronoidectomy was followed by submucosa tunneling through two vertical intraoral incisions to fixate the temporalis tendon to the perioral location. Oral commissure excursion, upper lip and commissure height differences, and smile angle were measured. Postoperatively, the symmetry of commissure excursion improved in repose (affected side: 114.6 ± 7.0 mm, non-affected side: 115.2 ± 4.9 mm, p = 0.134), while asymmetry arose in smiling (affected side: 30.7 ± 3.4 mm, non-affected side: 34.5 ± 4.4 mm, p = 0.001). Furthermore, the postoperative smile angle demonstrated insufficient vertical movement on the affected side during smiling (affected side: 115.6 ± 5.8°, non-affected side: 118.4 ± 4.9°, p = 0.002) but no significant difference in repose (p = 0.134). Within the limitations of the study it seems that intraoral orthodromic temporalis transfer yields excellent resting symmetry, but smile asymmetry may occur owing to insufficient oral commissure excursion. Nevertheless, as a minimally invasive surgery, this technique can obviate visible scars and benefit patients wishing for the same and can have excellent resting symmetry.

Artificial intelligence-based numerical analysis of the quality of facial reanimation: A comparative retrospective cohort study between one-stage dual innervation and single innervation

This study aimed to investigate the difference in facial reanimation surgery using functional gracilis muscle transfer between the masseteric nerve alone and its combined use with cross face nerve graft (CFNG), which has not been explored before. A novel analysis method based on artificial intelligence (AI) was employed to compare the outcomes of the two approaches. Using AI, 3-dimensional facial landmarks were extracted from 2-dimensional photographs, and distance and angular symmetry scores were calculated. The patients were divided into two groups, with Group 1 undergoing one-stage CFNG and masseteric nerve dual innervation, and Group 2 receiving only masseteric nerve. The symmetry scores were obtained before and 1 year after surgery to assess the degree of change. Of the 35 patients, Group 1 included 13 patients, and Group 2 included 22 patients. The analysis revealed that, in the resting state, the change in the symmetry score of the mouth corner showed distance symmetry (2.55 ± 2.94, 0.52 ± 2.75 for Group 1 and Group 2, respectively, p = 0.048) and angle symmetry (1.21 ± 1.43, 0.02 ± 0.22 for Group 1 and Group 2, respectively, p = 0.001), which were significantly improved in Group 1, indicating a more symmetric pattern after surgery. In the smile state, only the angle symmetry was improved more symmetrically in Group 1 (3.20 ± 2.38, 1.49 ± 2.22 for Group 1 and Group 2, respectively, p = 0.041). Within the limitations of the study it seems that this new analysis method enabled a more accurate numerical symmetry score to be obtained, and while the degree of mouth corner excursion was sufficient with only the masseteric nerve, accompanying CFNG led to further improvement in symmetry in the resting state.

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.

Oral competence following facial nerve paralysis: Functional and quality of life measures

PURPOSE

Oral competence refers to the maintenance of lip closure with sufficient strength to prevent anterior spillage of saliva, food and fluid, and to clearly articulate labial sounds. Despite facial nerve paralysis having an impact on eating, drinking and communicating, little research has been done in this area.

METHOD

Studies examining oral competence associated with a diagnosis of facial nerve paralysis were considered using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement checklists and evaluated for their risk of bias using the RevMan Risk of Bias Tool.

RESULT

44 articles were examined. There was an over-representation of case-series and cohort studies. All studies carried a high risk of bias due to lack of (a) validated outcome measures, (b) comparison group and (c) blinding or randomised assessors and participants. Studies primarily examined facial nerve intervention for the purpose of restoring smiling or facial aesthetics rather than oral competence.

CONCLUSION

Whilst oral competence is often compromised after a facial nerve paralysis, it is inconsistently measured, managed and described. Further studies are required to examine the (a) incidence, (b) severity and (c) impact on quality of life relating to oral incompetence using validated measures at consistent time intervals.

Workhorse Free Functional Muscle Transfer Techniques for Smile Reanimation in Children with Congenital Facial Palsy: Case Report and Systematic Review of the Literature

BACKGROUND

Pediatric facial palsy represents a rare multifactorial entity. Facial reanimation restores smiling, thus boosting self-confidence and social integration of the affected children. The purpose of this paper is to present a systematic review of microsurgical workhorse free functional muscle transfer procedures with emphasis on the long-term functional, aesthetic, and psychosocial outcomes.

MATERIALS AND METHODS

We performed a literature search of the PubMed database from 1995 to 2019 using the following search strategy: "facial paralysis"[Title/Abstract] OR "facial palsy"[Title]. We used as limits: full text, English language, age younger than 18 years, and humans. Two independent reviewers performed the online screening process using Covidence. Forty articles met the inclusion criteria. The protocol was aligned with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and was registered at the International Prospective Register of Systematic Reviews (PROSPERO, CRD42019150112) of the National Institute for Health Research.

RESULTS

Free functional muscle transfer procedures include mainly segmental gracilis, latissimus dorsi, and pectoralis minor muscle transfer. Facial reanimation procedures with the use of the cross-face nerve graft (CFNG) or masseteric nerve result in almost symmetric smiles. The transplanted muscle grows harmoniously along with the craniofacial skeleton. Muscle function and aesthetic outcomes improve over time. All children presented improved self-esteem, oral commissure opening, facial animation, and speech.

CONCLUSIONS

A two-stage CFNG plus an FFMT may restore a spontaneous emotive smile in pediatric facial palsy patients. Superior results of children FFMT compared to adults FFMT are probably attributed to greater brain plasticity.

Microsurgical Reconstruction of the Smile: A Critical Analysis of Outcomes

BACKGROUND

Facial paralysis is a significant problem with functional, psychological, and esthetic consequences. Free muscle transfer for reanimation of the smile has been established as the preferred reconstructive method. However, little has been reported on the complications after this procedure. We sought to perform a critical analysis of these complications and their ultimate outcomes.

METHODS

A retrospective review was performed on consecutive patients undergoing microsurgical reconstruction of the smile by the senior author from 2013 through 2017. Patient demographics including age, race, body mass index, and medical comorbidities were recorded. The cause of facial palsy and type of microsurgical reconstruction were assessed. Patient outcomes including complications and management of the complication were analyzed. All statistical analyses were performed using nonparametric analyses.

RESULTS

We identified 17 patients who underwent microsurgical reconstruction of the smile, with 1 patient undergoing bilateral procedures, for a total of 18 microsurgical smile reanimation procedures performed. Sixteen of these were 1-stage reconstructions with the coaptation of the nerve to the masseter, whereas 2 were 2-stage reconstructions using cross-facial nerve grafts. The gracilis muscle was used as the donor muscle in all cases. The patients had a median age of 26.5 and a median follow-up of 1.04 years from surgery. There were no major early complications observed in our cohort. Eight (44.4%) reanimations developed a minor complication that required subsequent reoperation. The reoperations were performed at a median of 0.97 years after the microsurgical procedure. The most common indication for reoperation was lateral retraction of the insertion of the transplanted muscle, which occurred in 5 (62.5%) patients. One patient underwent surgical exploration for an abrupt loss of transplanted muscle function after trauma to the cheek. Another patient had less than expected transplanted muscle activity at 1 year postoperatively and underwent exploration of the cross-facial nerve graft and a neurorrhaphy revision. Lastly, 1 patient developed significant rhytids over the transplanted muscle secondary to tethering of the skin to the underlying muscle. This patient underwent 2 subsequent revisions, with placement of acellular dermal matrix between the muscle and skin and fat grafting. All patients had functional animation of the transplanted muscle postoperatively.

CONCLUSIONS

Complications occurred in 44.4% of patients undergoing microsurgical reanimation of the smile. Most complications were minor in nature and were readily addressed with advancement of the transplanted muscle. All patients in our series had muscle function after the muscle transplantation.

Long-term outcomes of Gillies and McLaughlin's dynamic muscle support in irreversible facial paralysis: A retrospective single-centre study with 25-year follow-up

The aim of this study was to evaluate the long-term outcomes of Gillies and McLaughlin's dynamic muscle support with regard to functional outcomes and assess possible effects of comorbidities on both functional outcomes and reoperation and complication rates. A retrospective single-centre study was conducted in all patients (n = 154) who underwent surgical correction of irreversible facial paralysis from 1994 to 2018. Patients with either Gillies procedure or McLaughlin's dynamic muscle support or a combination of these techniques were included in the analysis. Data on reoperations, comorbidities, complications, functional outcomes and patient satisfaction were analysed. Sixty-nine patients had Gillies and McLaughlin combination, 12 patients had Gillies and 33 patients had McLaughlin procedure alone. Patient satisfaction was generally high (>80%) and highest when McLaughlin procedure alone was performed and in patients without comorbidities. Reoperations were performed in 80 patients (70%; mean 2.2 ± 1.7) and complications affected 16 patients (14%). Smile ability and movement control of the corner of the mouth were achieved in >85% of patients operated, whereas complete eyelid closure and facial symmetry at rest were attained in only 46%‒68% of patients. Patients with no underlying medical conditions were able to smile more often, had motor control of the corner of the mouth, better facial symmetry at rest and fewer complications. Although newer surgical techniques are offered in many centres, this study shows that conventional facial reanimation of irreversible facial paralysis with Gillies or McLaughlin's dynamic muscle support or a combination of both produces yield good results and, therefore, continues to be a viable treatment option for many patients.

Effectiveness and safety of the use of gracilis muscle for dynamic smile restoration in facial paralysis: A systematic review and meta-analysis

BACKGROUND

Smiling is a fundamental component of social interactions. Significant challenges arise for patients with facial palsy. One of the key procedures for dynamic smile restoration is the microneurovascular transfer of a gracilis muscle. We aimed to assess the effectiveness and safety of dynamic smile reanimation surgery using the free gracilis muscle unit in patients with facial palsy.

METHODS

We conducted a systematic review and meta-analysis of studies reporting surgical outcomes of dynamic smile restoration using free gracilis muscles identified from EMBASE, Medline, and Web of Science databases from their inception to March 15, 2018. Two-stage screening and data extraction were performed by two independent reviewers. Pooled proportions were calculated using random-effects models.

RESULTS

Thirty-one studies including 1647 patients who underwent 1739 free gracilis flaps were included. Twelve (38.7%) studies measured perioperative smile excursion change using six different tools. Six of these studies were homogeneous and were used in meta-analyses of smile excursion improvement, which revealed a mean change of 7.5 mm (95% CI 6.0-9.0 mm, I² 86.7%) perioperatively. Twenty (64.5%) studies reported perioperative complications, and pooled proportions of flap failures were of 2.9% (95% CI 1.3-4.5%, I² 47.7%).

CONCLUSIONS

Dynamic smile restoration using a free gracilis muscle may represent an effective procedure to regain oral commissure motion and is associated with an approximately 3% rate of flap failure. Masseteric nerve coaptations lead to larger improvements in perioperative smile excursion (10 mm) than cross-facial nerve grafts (6.8 mm). Future studies with homogeneous reporting of smile excursion and patient-reported outcome measures are needed.