Facial Paralysis Grading System: A New and Simple Smile Excursion Score for Evaluating Facial Reanimation Surgery

Beyond the smile: a systematic review of diagnostic tools for peripheral facial paralysis

BACKGROUND

Effective rehabilitation of peripheral facial paralysis (PFP) requires reliable assessment tools. This systematic review aimed to identify and validate instruments used in PFP rehabilitation, categorizing them according to the ICF framework.

METHODS

A comprehensive search was conducted across PubMed, Cinahl, Web of Science, and Scopus up to April 2024. Observational analytical studies and one non-randomized controlled trial that validated tools for assessing PFP were included.

RESULTS

Thirty-three studies were included, covering twenty different tools. Seventeen tools were related to the "Structure and Function" domain, while three addressed "Activity and Participation." The Sunnybrook and House-Brackmann scales were the most extensively studied. The Sunnybrook scale exhibited excellent intra- and inter-rater reproducibility and internal validity, making it suitable for clinical use. The House-Brackmann scale was user-friendly but had limitations in reproducibility and sensitivity to subtle differences, which newer versions like the FNGS 2.0 aimed to address. The FAME scale showed promise by reducing subjective scoring. Computerized tools, such as eFACE and A-FPG, and instruments for lip asymmetry and ocular involvement demonstrated potential but require further validation. The Facial Disability Index and the FaCE Scale were validated for assessing disability and participation restrictions.

CONCLUSION

This review identified several validated tools for PFP assessment, with the Sunnybrook and House-Brackmann scales being the most reliable. While emerging tools and computerized programs show promise, they need further validation for routine clinical use. Integrating validated tools into clinical practice is essential for comprehensive assessment and effective rehabilitation of PFP.

Surgical Treatments for Facial Aberrant Reinnervation Syndrome: A Systematic Review

Background: Facial aberrant reinnervation syndrome is characterized by aberrant facial muscle reinnervation after facial nerve injury producing facial synkinesis, hypertonicity, and muscle spasm. Objective: To systematically review the surgical treatments for facial aberrant reinnervation syndrome and assess their effectiveness as measured by patient-reported outcomes, physician-graded outcomes, or computer-automated grading systems. Methods: We conducted a systematic review using PubMed, Embase, and Cochrane CENTRAL in accordance with PRISMA guidelines. Texts reporting outcomes of any surgical treatment for facial aberrant reinnervation syndrome from 2003 to 2023 were included. Results: After screening, 25 studies with 731 patients were included. Surgical procedures included selective neurectomy (SN), selective myectomy (SM), cross-facial nerve graft, masseter nerve transfer, and gracilis muscle transfer. All surgical techniques and combinations showed significant improvement in at least one clinical outcome measure from baseline (p < 0.05), although one study found no significant improvement. Thirty different outcome measures were used, the most common being the FaCE and eFACE scales (seven studies each). Conclusions: All surgical procedures in this review yield improved clinical outcome measures for facial aberrant reinnervation syndrome, with SN and SM being the dominant surgical treatments. Standardized outcome assessment and more nuanced patient evaluation are necessary to determine the most effective surgical treatments.

Age-related outcomes of facial reanimation surgery using gracilis free functional muscle transfer innervated by the masseteric nerve: A retrospective cohort study

BACKGROUND

The free functional muscle gracilis transfer is an established approach in facial reanimation surgery; however, the significance of its neurotization and the patient's age is still inconclusive. Several donor nerves are available for facial reanimation using the free functional gracilis muscle transfer.

OBJECTIVE

This retrospective cohort study investigates whether the masseteric nerve is an equally reliable donor nerve in both older and younger patients.

METHODS

We included 46 patients (13-71 years, male and female) who underwent nerve-to-masseter (NTM)-driven free functional muscle transfer (FFMT) between January 2008 and December 2019. Patients were distributed into three cohorts according to their age at surgery. We assessed the facial symmetry before and after surgery using the pupillo-modiolar angle. Commissure height and excursion deviation were measured with the Emotrics software. Patient-reported outcome measurements were taken using the Facial Clinimetric Examination (FaCE) scale.

RESULTS

All patients had successful flap innervation, except for one patient in the middle-aged cohort (31-51 years). The postoperative facial symmetry at rest, smiling, and laughing was analyzed with the pupillo-modiolar angle and the Emotrics software and showed similar results between all cohorts. The FaCE scale showed similar scores for the middle-aged (31-51 years) cohort and the senior cohort (52-71 years). The social function score in the senior cohort was higher than in the middle-aged cohort, without statistical significance. One patient in the middle-aged (31-51 years) cohort and the senior cohort (52-71 years), respectively, underwent emergency revision due to impaired flap perfusion and could be salvaged.

CONCLUSIONS

NTM-driven FFMT for facial reanimation is a safe and reliable procedure across all age groups of patients.

Assessing Adult Patients with Facial Deformities for Injectable Treatment: Do Current Classification Systems and Methodologies Meet Important Patient Needs?

BACKGROUND

Many individuals are affected by facial deformities. Injectable aesthetic treatments can often be used to improve appearance and/or dynamic function. However, to best meet the needs of these patients, broadly applicable methodologies are required for classifying the deformity, assessing severity, and developing a treatment strategy.

OBJECTIVE

To assess whether any published systems could be used for this purpose.

METHODS

Thirty-eight searches were conducted in PubMed (1999-2019; in English). Forty-two publications were identified describing novel classification systems for adult facial deformity. They were analyzed against a checklist of 10 characteristics defining an "optimal" system-based on appropriate anatomical coverage, wide usability across types of deformity, user-friendliness, applicable underlying methodology, and ability to guide treatment with injectables.

RESULTS

None of the systems met more than 7 of the 10 checklist criteria; none were usable across multiple types of deformity or provided a recommendation for treatment with injectables.

CONCLUSION

There remains a need for a broadly applicable system for classifying adult facial deformities ahead of injectable therapy. The checklist provides a developmental framework. With the increasing popularity and accessibility of injectables, this diverse and complex demographic is at risk of mismanagement without superior methods for devising treatment strategies.

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.

Age-related outcome of facial reanimation surgery using cross face nerve graft and gracilis free functional muscle transfer-A retrospective cohort study

BACKGROUND

Free functional muscle transfer has become the criterion standard for the treatment of long-standing flaccid facial paralysis. Clinical experience suggests that a two-stage approach using a cross-face nerve graft (CFNG) as a donor nerve for free functional muscle transfers (FFMT) is less successful in older patients when compared to the pediatric population. However, clear data and scientific evidence are still rare. This study examines the age-related outcome of CFNG-driven FFMT.

METHODS

Twenty-eight patients with a mean age of 20.73 years (ranging 5-51 years) who received two-stage facial reanimation with CFNG-driven gracilis FFMT at our institution from 1998 to 2019 were included. The ipsilateral sural nerve was used as CFNG. After 12 months, the ipsilateral gracilis muscle was used as FFMT. Patients were distributed equally into three cohorts according to their age. We assessed facial symmetry before and after facial reanimation measuring the angle between the interpupillary and the intermodiolar line (pupillo-modiolar angle). Additionally, the commissure height was measured using the Emotrics software.

RESULTS

The mean follow-up of the pediatric, young adults and the middle-aged cohort was 29.5 ± 7.3, 24.9 ± 6.3, and 25.5 ± 12.4 months, respectively. One patient suffered flap loss due to flap ischemia. Four patients suffered insufficient innervation of the FFMT. Otherwise no major complication occurred. The likelihood of successful innervation of the FFMT was significantly higher in patients younger than 31 years (100% vs. 50%; p = .003). Smiling facial symmetry (pupillo-modiolar angle) significantly improved in the pediatric cohort (5-16 years; 8.68° ± 0.69° to 1.48° ± 0.67°; p < .001) and the young adults' cohort (17-30 years; 11.55° ± 1.95° to 4.62° ± 1.08°; p = .005), but improved only slightly in the middle-aged cohort (31-51 years; 11.77° ± 1.16° to 9.4° ± 1.8° p = .27). The postoperative smiling symmetry showed a significant correlation with increasing age (r = .62, p < .001). The smiling commissure height deviation significantly improved in the pediatric cohort (5-16 years; 6.5-2.3 mm; p = .006) and the postoperative result was significantly better than the middle-aged group (31-51 years; 2.3 vs. 7.5 mm; p = .02).

CONCLUSIONS

The outcome of CFNG-driven gracilis FFMT is age-related. Static as well as dynamic facial symmetry after two-stage facial reanimation was best in the pediatric and young adult population. For older patients, other approaches like the nerve-to-masseter-driven FFMT should be considered.

Artificial Intelligence-Driven Video Analysis for Novel Outcome Measures After Smile Reanimation Surgery

Background: Since facial paralysis is a dynamic condition, the analysis of still photographs is not sufficient for measurement of facial reanimation outcomes. This study aimed at evaluating an artificial intelligence (AI)-driven software as a novel video assessment tool for smile reanimation surgery and at comparing it with the Terzis score. Methods: Patients with facial paralysis undergoing smile reanimation surgery between January 2008 and April 2020 were eligible for this retrospective study. Inclusion criteria were at least 6 months of follow-up and availability of both pre- and post-operative video documentation. The software output was given as intensity score (IS) values between 0 and 1, representing emotions/action units (AUs) that are absent or fully present, respectively. Results: During the study period, 240 patients underwent facial reanimation surgery, of whom 63 patients met the inclusion criteria. Postoperatively, the median IS of the happiness emotion and lip corner puller AU increased significantly (p < 0.001). There was a positive correlation of Terzis score with the IS of happiness emotion (r = 0.8) and lip corner puller AU (r = 0.74). Conclusions: The novel AI-driven video analysis is strongly correlated with the Terzis score and shows promise for objective functional outcome evaluation after smile reanimation surgery.

Holistic reconstruction of mandible defect, lower lip and chin sensation, and smile reanimation in an advanced gum cancer patient: A case report

Facial deformity, facial paralysis, and sensory loss are inevitable after some head and neck tumor resection and reconstruction, especially in high stage cancer. To overcome these obstacles, we present a case of T4a gum cancer patient (41-year-old) who received holistic reconstruction of the mandible defect via an osteo-peroneal-artery-perforator combined flap for defect coverage and cross-mental nerve graft for lower lip and chin sensation at the primary stage, followed by ipsilateral facial nerve (lower trunk) innervated gracilis functioning free muscle transplantation for facial reanimation and correction of the sunken face 3 years later. After 4.5 years of follow-up, the patient was satisfied with his appearance, and obtained a spontaneous and symmetrical smile without sensory deficit. This experience showed a possible solution to the reconstruction for complicated head and neck cancer patients.

Morbidity of marginal mandibular nerve post vascularized submental lymph node flap transplantation

BACKGROUND

This study investigated the morbidity of the marginal mandibular nerve (MMN) post vascularized submental lymph node (VSLN) harvest.

METHODS

The VSLN with sacrifying or preserving the medial platysma was retrospectively classified as group I or II. Midline deviation and horizontal tilt were subjectively evaluated. Horizontal, vertical, and "area distribution" of the lower lip excursions of the surgical site were objectively compared with the nonsurgical site.

RESULTS

Seventeen patients in group I and 12 patients in group II were included. At a median follow-up of 48.6 ± 16.8 months in group I and 14.8 ± 7.5 months in group II, no MMN palsy was found in both groups. Median midline deviation and horizontal tilt were 4.53 ± 0.52 and 5 ± 0 in group I and 4.67 ± 0.65 and 5 ± 0 in group II, respectively (P = .419 and 1.000). Median horizontal, vertical and area of distribution of lower lip excursions were 97.5 ± 12.3%, 98.8 ± 14.4% and 87.2 ± 14.7% in group I, and 99.3 ± 15.1%, 95.8 ± 8.2% and 84.2 ± 14.2% in group II, respectively (P = .679, .948 and .711).

CONCLUSION

The VSLN flap was a safe procedure with minimal MMN morbidity.

Significance of the Marginal Mandibular Branch in Relation to Facial Palsy Reconstruction: Assessment of Microanatomy and Macroanatomy Including Axonal Load in 96 Facial Halves

BACKGROUND

The marginal mandibular branch (MMB) of the facial nerve provides lower lip symmetry apparent during human smile or crying and is mandatory for vocal phonation. In treating facial palsy patients, so far, little attention is directed at the MMB in facial reanimation surgery. However, isolated paralysis may occur congenital, in Bell's palsy or iatrogenic during surgery, prone to its anatomical course. A variety of therapies address symmetry with either weakening of the functional side or reconstruction of the paralyzed side. To further clarify the histoanatomic basis of facial reanimation procedures using nerve transfers, we conducted a human cadaver study examining macroanatomical and microanatomical features of the MMB including its axonal capacity.

METHODS

Nerve biopsies of the MMB were available from 96 facial halves. Histological processing, digitalization, nerve morphometry investigation, and semiautomated axonal quantification were performed. Statistical analysis was conducted with P < 0.05 as level of significance.

RESULTS

The main branch of 96 specimens contained an average of 3.72 fascicles 1 to 12, and the axonal capacity was 1603 ± 849 (398-5110, n = 85). Differences were found for sex (P = 0.018), not for facial sides (P = 0.687). Diameters were measured with 1130 ± 327 μm (643-2139, n = 79). A significant difference was noted between sexes (P = 0.029), not for facial sides (P = 0.512.) One millimeter in diameter corresponded to 1480 ± 630 axons (n = 71). A number of 900 axons was correlated with 0.97 mm (specificity, 90%; sensitivity, 72%).

CONCLUSIONS

Our morphometric results for the MMB provide basic information for further investigations, among dealing with functional reconstructive procedures such as nerve transfers, nerve grafting for direct neurotization or babysitter procedures, and neurectomies to provide ideal power and authenticity.

Qualitative and Quantitative Analysis of Smile Excursion in Facial Reanimation: A Systematic Review and Meta-analysis of 1- versus 2-stage Procedures

Background:

Free functional muscle transfer has become a common treatment modality for smile restoration in long-lasting facial paralysis, but the selection of surgical strategy between a 1-stage and a 2-stage procedure has remained a matter of debate. The aim of this study was to compare the quantitative and qualitative outcomes of smile excursion between 1-stage and 2-stage free muscle transfers in the literature.

Methods:

A comprehensive review of the published literature between 1975 and end of January 2017 was conducted.

Results:

The abstracts or titles of 2,743 articles were screened. A total of 24 articles met our inclusion criteria of performing a quantitative or qualitative evaluation of a free-functioning muscle transfer for smile restoration. For the purpose of meta-analysis, 7 articles providing quantitative data on a total of 254 patients were included. When comparing muscle excursion between 1-stage and 2-stage procedures, the average range of smile excursion was 11.5 mm versus 6.6 mm, respectively. For the purpose of systematic review, 17 articles were included. The result of the systematic review suggested a tendency toward superior functional results for the 1-stage procedure when comparing the quality of smile.

Conclusions:

The results of this review must be interpreted with great caution. Quantitative analysis suggests that 1-stage procedures produce better excursion than 2-stage procedures. Qualitative analysis suggests that 1-stage procedures might also produce superior results when based on excursion and symmetry alone, but these comparisons do not include one important variable dictating the quality of a smile—the spontaneity of the smile. The difficulty in comparing published results calls for a consensus classification system for facial palsy.

Postparalysis facial synkinesis: clinical classification and surgical strategies

Supplemental Digital Content is available in the text.

Background:

Postparalysis facial synkinesis (PPFS) can occur after any cause of facial palsy. Current treatments are still inadequate. Surgical intervention, instead of Botox and rehabilitation only, for different degrees of PPFS was proposed.

Methods:

Seventy patients (43 females and 27 males) with PPFS were enrolled since 1986. They were divided into 4 patterns based on quality of smile and severity of synkinesis. Data collection for clinically various presentations was made: pattern I (n = 14) with good smile but synkinesis, pattern II (n = 17) with acceptable smile but dominant synkinesis, pattern III (n = 34) unacceptable smile and dominant synkinesis, and pattern IV (n = 5) poor smile and synkinesis. Surgical interventions were based on patterns of PPFS. Selective myectomy and some cosmetic procedures were performed for pattern I and II patients. Extensive myectomy and neurectomy of the involved muscles and nerves followed by functioning free-muscle transplantation for facial reanimation in 1- or 2-stage procedure were performed for pattern III and many pattern II patients. A classic 2-stage procedure for facial reanimation was performed for pattern IV patients.

Results:

Minor aesthetic procedures provided some help to pattern I patients but did not cure the problem. They all had short follow-up. Most patients in patterns II (14/17, 82%) and III (34/34, 100%) showed a significant improvement of eye and smile appearance and significant decrease in synkinetic movements following the aggressively major surgical intervention. Nearly, all of the patients treated by the authors did not need repeated botulinum toxin A injection nor require a profound rehabilitation program in the follow-up period.

Conclusions:

Treatment of PPFS remains a challenging problem. Major surgical reconstruction showed more promising and long-lasting results than botulinum toxin A and/or rehabilitation on pattern III and II patients.