Ocular-oral synkinesis caused by partial injury of the zygomatic and buccal branches of the facial nerve after mid-face trauma.

BACKGROUND: Facial nerve paralysis induced by acute traumatic facial nerve injuries limited to the zygomatic and buccal branches shows unique complications, such as strong co-contractions of the lower facial muscles around the lips during voluntary blinking (ocular-oral synkinesis). We investigated the characteristics of facial complications after facial nerve injury in the mid-face area and reported the treatment results. METHODS: A total of 21 patients with facial nerve injuries to the zygomatic and/or buccal branches were evaluated for the degree of facial synkinesis and mouth asymmetry. Patients with mild-to-moderate symptoms were treated using physical rehabilitation therapy combined with botulinum toxin (Botox) injection, and patients with severe or uncontrolled symptoms were treated using surgical therapy. RESULTS: Initial/final mean synkinesis scores and mouth asymmetry degrees were 2.17/1.75 and 0.85/0.66 in the physical therapy group and 3.11/0.78 and 2.41/-0.31 in the surgery group, respectively. Physical therapy with Botox injection alone did not show significant improvements in synkinetic symptoms of the patients with mild-to-moderate synkinesis (p > 0.05), whereas surgical therapy resulted in significant improvements in synkinesis and mouth asymmetry (p < 0.05). CONCLUSIONS: Surgical treatment is an effective adjustment procedure for the management of facial complications in patients with severe or uncontrolled synkinesis after facial nerve injury to the mid-face area.

Marcus-Gunn jaw winking syndrome: case series study and management algorithm.

PURPOSE: To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS). METHODS: Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL). RESULTS: Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia. CONCLUSIONS: Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.

Validation of the Spanish version of the Electronic Facial Palsy Assessment (eFACE).

PURPOSE: The clinician-graded electronic facial paralysis assessment (eFACE) is a relatively new digital tool for assessing facial palsy. The present study aimed to determine the validity and reliability of the Spanish version of the eFACE. METHODS: Forward-backward translation from the original English version was performed. Videos and photographs from 65 adult patients with unilateral facial paralysis (any severity, time course, and etiology) were evaluated twice by five otolaryngologists with varying levels of experience in facial palsy evaluation. Internal consistency was measured using Cronbach's α and the intra- and inter-rater reliability were measured using intraclass correlation coefficient. Concurrent validity was established by calculating Spearman's rho correlation (ρ) between the eFACE and the House-Brackmann scale (H-B) and Pearson's correlation (r) between the eFACE and the Sunnybrook Facial Grading System (SFGS). RESULTS: The Spanish version of the eFACE showed good internal consistency (Cronbach's α > 0.8). The intra-rater reliability was nearly perfect for the total score (intraclass correlation coefficient: 0.95-0.99), static score (0.92-0.96), and dynamic score (0.96-0.99) and important-to-excellent for synkinesis score (0.79-0.96). The inter-rater reliability was excellent for the total score (0.85-0.93), static score (0.80-0.90), and dynamic score (0.90-0.95) and moderate-to-important for the synkinesis score (0.55-0.78). The eFACE had a very strong correlation with the H-B (ρ = - 0.88 and - 0.85 for each evaluation, p < 0.001) and the SFGS (r = 0.92 and 0.91 each evaluation, p < 0.001). CONCLUSION: The Spanish version of the eFACE is a reliable and valid instrument for assessment of facial function in the diagnosis and treatment of patients with facial paralysis.

Hypoglossal Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-Analysis.

Background: Hypoglossal-facial nerve (12-7) anastomosis can restore symmetry and voluntary movement on the face in patients with facial nerve paralysis. Traditional 12-7 transfer includes direct end-to-end nerve anastomosis, sacrificing the entire hypoglossal nerve. Contemporary, end-to-side anastomosis, or split anastomosis techniques limit tongue morbidity by preserving some hypoglossal nerve. Direct outcome comparisons between these techniques are limited. Objective: To compare reported outcomes of facial movement, tongue, speech, and swallow outcomes among the different types of hypoglossal-facial nerve anastomosis schemes. Evidence Review: For this systematic review and meta-analysis, a comprehensive strategy was designed to search PubMed, Scopus, and the Cochrane Database from inception to January 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, reporting guideline yielding 383 results. Any participant who underwent 12-7 transfer using any of the three techniques, with or without an interposition graft, and had documented preoperative and postoperative evaluation of facial nerve function with a validated instrument such as House-Brackmann (HB), was considered for inclusion. Secondary outcomes of synkinesis, tongue atrophy, and speech or swallowing dysfunction were also compared. Forty-nine studies met inclusion criteria, representing data from 961 total patients who underwent 12-7 transfer. Results: The proportion of good HB outcomes (HB I-III) did not differ by anastomosis type: End-to-side and end-to-end anastomosis (73% vs. 59%, p = 0.07), split and end-to-end anastomosis (62% vs. 59%, p = 0.88), and end-to-side anastomosis and split anastomosis (73% vs. 62%, p = 0.46). There was no difference in reported synkinesis rates between the anastomosis types. However, end-to-side anastomosis (z = 6.55, p < 0.01) and split anastomosis (z = 3.58, p < 0.01) developed less tongue atrophy than end-to-end anastomosis. End-to-side anastomosis had less speech/swallowing dysfunction than end-to-end anastomosis (z = 3.21, p < 0.01). Conclusion: End-to-side and split anastomoses result in similar HB facial nerve outcomes as the traditional end-to-end 12-7 anastomosis. End-to-side anastomosis has decreased complications of tongue atrophy and speech/swallow dysfunction compared to end-to-end anastomosis. In addition, split anastomosis has decreased rates of tongue atrophy compared to end-to-end anastomosis.

Different Cortical Activation of Facial Synkinesis Patients with Different Course of Disease: A Task fMRI Study.

Facial synkinesis is a disease characterized by unintentional activation of facial muscles, which causes that the patients cannot control their facial expressions independently. Previous studies have shown that its pathogenesis is related to the reorganization of cerebral cortex, but it remains unclear what brain changes the patients have at different stage of the disease. For this study, we recruited 30 patients with facial synkinesis and 19 healthy control subjects from Shanghai Huashan Hospital. All participants completed bilateral blinking and grinning tasks while functional magnetic resonance imaging (fMRI) data was collected. We measured the brain activation strength of each task and observed the activation similarity of the ipsilateral tasks. Then we explored the correlation between activation pattern and clinical scale. Results showed different activation pattern along the courses of disease for blinking and grinning task, which may be due to the inconsistent process of cortical reorganization. The late stage group activated more in blinking task, but the least in grinning tasks, especially on the affected side (p<0.001 at voxel level, p<0.05 at cluster level, FWE corrected). Compared with healthy controls, the activation of patients between tasks on the affected side is more similar(p<0.05). There was a negative correlation in right postcentral gyrus between activation similarity and scale scores (symmetry of voluntary movement scores: R = -0.469, p = 0.009). This could be attributed to the rearrangement of the nervous system following facial nerve injury, leading to incorrect connections between nerves and muscles. Our study may be helpful for understanding mechanism of facial synkinesis and provide basis for the stage-dependent diagnosis and treatment.

[Rehabilitation of patients with complications of facial nerve neuropathy]. / Reabilitatsiya patsientov s oslozhneniyami neiropatii litsevogo nerva.

OBJECTIVE: To compare the effectiveness of physical rehabilitation (PR) and botulinum therapy in the treatment of facial nerve neuropathy (FNN) complications. MATERIAL AND METHODS: Sixty-eight patients with FNN of various etiologies, including 70 women and 6 men aged 38 [31; 46] years, were studied. Time to seek medical help was 717 [256; 1638] days. Diagnosis of the motor pattern included determining the strength of facial muscles, identifying complications - muscle hypertonicity and synkinesis, assessment with the House-Brackmann Grading System, the Facial Nerve Grading System 2.0 and the Sunnybrook facial grading system. All patients were prescribed a standard PR complex, additionally muscle relaxation was performed on both sides by injections of Incobotulinumtoxin A (BTA) - BTA group (n=34; 44.7%) or special PR techniques - physiotherapy group (n=42; 55.3%). RESULTS: The both groups are comparable by age, sex, etiology and duration of treatment, however, patients in the BTA group have more severe stage of FNN (U=534.5; p=0.031). There is a limitation in the volume of active movements in patients with muscles hypertonicity of the affected side, which was associated with insufficient muscle strength. In the BTA group, the severity of complications (muscles hypertonicity and synkinesis) is decreased on the affected side, and in 1/4 of the cases it is accompanied by an increase of muscles strength. In the physiotherapy group, the decrease in the severity of complications is less significant, but is associated with an increase of muscles strength (χ2=45.505; p<0001). CONCLUSIONS: PR and botulinum toxin therapy are effective methods of treating FNN complications. Special PR techniques for relaxing and stretching muscles are applicable for the prevention and treatment of mild disorders. Botulinum therapy allows achieving a significant stable clinical effect in the treatment of moderate and severe complications (muscle hypertonicity and synkinesis).

Clinical application of physical therapy in facial paralysis treatment: A review.

This review aims to summarize recent studies regarding the specific modalities of physical therapy as a form of treatment for patients with facial paralysis, analyze the different components of physical therapy, and provide healthcare providers with guidance for their best practice in treating patients with facial paralysis. This paper will discuss the mechanism, indications, and impact factors for facial retraining, evaluate the standards for facial retraining, the creation of a treatment plan, and analyze the combined use of facial retraining with botulinum toxin injections and the application of facial retraining in post facial reanimation patients. Other modes of physical therapy, including electrical stimulation, dry needling, and acupuncture, will be addressed. Lastly, the application of new digital technology will be discussed.

Exploration of rich-club reorganization in facial synkinesis: insights from structural and functional brain network analysis.

Facial palsy therapies based on cortical plasticity are in development, but facial synkinesis progress is limited. Studying neural plasticity characteristics, especially network organization and its constitutive elements (nodes/edges), is the key to overcome the bottleneck. We studied 55 participants (33 facial synkinesis patients, 22 healthy controls) with clinical assessments, functional magnetic resonance imaging (fMRI), and diffusion tensor imaging (DTI). We analyzed rich-club organization and metrics of structural brain networks (rich-club coefficients, strength, degree, density, and efficiency). Functional brain network metrics, including functional connectivity and its coupling with the structural network, were also computed. Patients displayed reduced strength and density of rich-club nodes and edges, as well as decreased global efficiency. All nodes exhibited decreased nodal efficiency in patients. Patients had significantly increased functional connectivity and decreased structural-functional coupling strength in rich-club nodes, rich-club edges, and feeder edges. Our study indicates that facial synkinesis patients have weakened structural connections but enhanced functional transmission from rich-club nodes. The loss of connections and efficiency in structural network may trigger compensatory increases in functional connectivity of rich-club nodes. Two potential biomarkers, rich-club edge density and structural-functional coupling strength, may serve as indicators of disease outcome. These findings provide valuable insights into synkinesis mechanisms and offer potential targets for cortical intervention.

Botulinum toxin treatment of the buccinator muscle facial synkinesis: A systematic review.

BACKGROUND: The purpose of this review is to provide an overview of the available literature assessing the treatment of botulinum toxin injections for the treatment of synkinesis of the buccinator muscle in patients with peripheral facial palsy (PFP). MATERIALS AND METHODS: A multi database search was performed, including the following databases: Pubmed, Medline, Embase, and the Cochrane Library. Each database was searched from its earliest date until 8 June 2023. The following outcome measures were extracted from the articles when available: subjective, somatic, and psychological effects on the patients and objective outcomes such as the House-Brackmann, Sunnybrook and Sydney scores. The methodological quality of the included studies was rated using the Newcastle-Ottawa scale for nonrandomised trials. RESULTS: The primary literature search generated 37 articles. After removing duplicates, 25 articles remained for abstract appraisal, of which 20 underwent full-text appraisal, resulting in 3 studies for analysis. All of these studies showed (significant) improvement in synkinesis either measured using the Synkinesis Assessment Questionnaire or subjectively measured by asking treated patients. CONCLUSION: The available literature supports the finding that botulinum toxin treatment of the buccinator muscle could be a welcome addition to facial synkinesis treatment and could significantly improve patient outcomes. In future studies, the efficacy of EMG-guided buccinator injections, optimal dose, and a validated measuring method could be beneficial in optimising treatment for patients with a PFP and synkinesis.

Minimization of facial synkinesis.

PURPOSE OF REVIEW: To summarize the treatment options available for the management of postparalytic facial synkinesis which include facial rehabilitation, chemodenervation, and a spectrum of surgical interventions. RECENT FINDINGS: Facial rehabilitation and botulinum toxin chemodenervation represent the foundation of facial synkinesis management, with specific treatment paradigms directed by individual patient needs. Evolving surgical approaches range from isolated selective myectomies or neurectomies to combination approaches which may incorporate various types of nerve transfer with gracilis free muscle transplantation. SUMMARY: Postparalytic facial synkinesis bears significant patient morbidity due to aesthetic and functional implications. Management strategies must balance patient goals with treatment risks and typically progress stepwise from the least to most invasive interventions. Emerging techniques reveal a convergence in approaches to facial reanimation and synkinesis mitigation.

Selective neurectomy for nonflaccid facial palsy.

PURPOSE OF REVIEW: To review the evolving role of selective neurectomy in the management of patients with synkinesis including the history of selective neurectomy, operative techniques, and clinical outcomes. RECENT FINDINGS: Modified selective neurectomy alone or in conjunction with other procedures achieves more durable outcomes based on objective measures such as time to recurrence of symptoms and units of botulinum toxin required postoperatively. This is also reflected on patient reported quality of life outcome measures. Regarding operative technique, lower rates of oral incompetence are reported with division of an average of 6.7 nerve branches as opposed to more branches. SUMMARY: Chemodenervation has long been the mainstay of treatment in facial synkinesis, but in recent years, the paradigm has begun to shift in favor of incorporating interventions with more durable outcomes such as modified selective neurectomy. Modified selective neurectomy is often performed with other simultaneous surgeries such as nerve transfer, rhytidectomy, lid surgery and static facial reanimation primarily to address periocular synkinesis and synkinetic smile. The outcomes have been favorable with improvement in quality-of-life measures and a decrease in botulinum toxin requirements.

Neuromuscular retraining therapy combined with preceding botulinum toxin A injection for chronic facial paralysis.

BACKGROUND: Neuromuscular retraining therapy (NMRT) is the central treatment for synkinesis. The efficacy of botulinum toxin type A (BTX-A) may be enhanced with the addition of physical therapy. OBJECTIVES: To investigate the effects of NMRT combined with preceding BTX-A injection (NMRT-B) on facial synkinesis and asymmetry in chronic facial paralysis. MATERIALS AND METHODS: We recruited 99 patients with unilateral facial paralysis and no recovery for > 6 months who underwent NMRT-B for > 1 year. The patients were scheduled to receive NMRT after 1-2 weeks of BTX-A injection. We used a computer-based numerical scoring system to evaluate the facial functions. Primary, secondary, and final facial movement scores were evaluated before and after 1 year of treatment. RESULTS: Patients with chronic facial paralysis who underwent NMRT-B exhibited improved facial movement after 1 year of treatment. NMRT-B provided satisfactory control of synkinesis and improved the primary movements. The mean primary and final facial movement scores were significantly increased after treatment, while the mean secondary facial movement scores were significantly decreased. CONCLUSIONS AND SIGNIFICANCE: NMRT-B improved the final facial movement in patients with chronic facial paralysis and synkinesis, regardless of the degrees of facial synkinesis and asymmetry before treatment.

Commentary on: "Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis," by Hetzler et al.

In this commentary, we discuss Hetzler et al.'s article, "Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis." The authors do an excellent job of presenting a guide for practitioners to use when initiating chemodenervation treatment for patients with nonflaccid facial paralysis. Standardization of outcome assessment tools and rigorous data collection will further refine treatment algorithms.

Chemodenervation Algorithm: Functional and Aesthetic Considerations for Facial Harmony in Patients with Post-Facial Paralysis Synkinesis.

Management of post-facial paralysis synkinesis has evolved for the past decade with diversification of neuromuscular retraining, chemodenervation, and advanced surgical reanimation techniques. Chemodenervation with botulinum toxin-A is a commonly used treatment modality for synkinesis patients. Treatment has shifted from solely weakening the unaffected contralateral facial musculature for rote symmetry to selective reduction of undesired or overactive synkinetic muscles, allowing for a more organized motion of the recovered musculature. Facial neuromuscular retraining should be considered a crucial component of treating patients with synkinesis along with soft tissue mobilization, but specifics of these are beyond the scope of this article. Our goal was to create a descriptive platform for our method of chemodenervation treatment in the evolving field of post-facial paralysis synkinesis. A multi-institutional and multidisciplinary comparison of techniques was performed with photograph and video creation, review, and discussion over an electronic platform with all authors. Anatomic specifics of each region of the face and individual muscles were considered. A muscle by muscle algorithm for synkinesis therapy was created to include chemodenervation with botulinum toxin that should be considered for patients suffering from post-facial paralysis synkinesis.

The Feasibility of An Automatical Facial Evaluation System Providing Objective and Reliable Results for Facial Palsy.

Facial palsy would lead to a series of physical and mental problems, as facial function plays an important role in various aspects of daily life. However, the current strategies for evaluating facial function relied heavily on raters and the results varied from the experience of raters. Thus, an objective and accurate facial evaluation system is always claimed. In this study, a customized automatical facial evaluation system (AFES) was proposed, which might have the potential to be employed as an adjunctive and efficient assessing method in clinic. In order to investigate the feasibility of AFES, ninety-two participants with facial palsy were recruited and received scale-based subjective manual evaluation (including mHBGS and mSFGS) and objective automatical evaluation of AFES (including aHBGS, aSFGS and indicators of facial regional features) at enrollment and after two weeks. The correlations between the results of the two methods were analyzed and the participants were stratified according to the severity of facial function for further analyses. Strong positive correlations between manual and automatical HBGS and SFGS were observed and higher correlations were reported in the participants with normal-mild and moderate facial palsy. Significant improvements in clinical scales and indicator of eye synkinesis were found in forty-two participants in two weeks. Furthermore, some of the indicators were correlated with scale scores (I4, I7) and one of them presented a significant change between the baseline evaluation and follow-up evaluation (I7). According to the results, AFES could be considered as a viable method to perform objective and reliable evaluation for patients with facial palsy and provide clarified results for prognosis.

Outcome evaluation using an artificial intelligence-based facial measurement software for facial nerve grafting in head and neck and skull base surgery.

BACKGROUND: Interposition nerve grafting is an indispensable technique for facial nerve reconstruction in head and neck, and skull base surgery. The prognostic factors are inconclusive, partly due to limited objective assessment systems for facial nerve function. This study aimed to apply an artificial intelligence (AI)-based facial asymmetry measurement system to assess facial nerve grafting outcomes. METHODS: We retrospectively reviewed data of 23 patients who underwent facial nerve grafting between 2011 and 2020. Oral asymmetry and synkinesis severity were measured using AI. RESULTS: Oral movement recovered at 12-18 months postoperatively. Postoperative radiotherapy and a larger number of anastomosed distal stumps were significantly associated with poor and good final oral symmetry, respectively. Synkinesis severity was weakly correlated with the degree of oral movement recovery. CONCLUSIONS: Oral function recovered without a strong correlation with synkinesis. Caution should be exercised in facial nerve grafting for cases with postoperative radiotherapy.

Neuromuscular retraining therapy for early stage severe Bell's palsy patients minimizes facial synkinesis.

OBJECTIVE: To explore whether early physical interventions, including neuromuscular retraining therapy, can minimize excessive movement or any unwanted co-contraction after a severe Bell's palsy. DATA SOURCES: From March 2021 to August 2022, the therapist treated Bell's palsy patients for the acute (<3 months, Group A), subacute (3-6 months, Group B) and chronic (> 6 months, Group C) stages of the condition. METHODS: We explored whether early physical interventions, including neuromuscular retraining therapy, can minimize facial synkinesis after a severe episode of Bell's palsy. Each patient was informed about the potential for synkinesis and the therapist explained that the main purpose of neuromuscular retraining therapy is to learn new patterns to minimize synkinesis. The facial function of Group A was compared to that of Groups B and C using the 'Synkinesis' scale of the Sunnybrook Facial Grading System. RESULTS: The final facial function score after neuromuscular retraining therapy was significantly associated with both the initial electroneuronographic degeneration rate and initial facial function. Early therapy did not prevent synkinetic movement in 84.7% of the patients. But, there was a significant difference between patients who started early neuromuscular retraining therapy and other groups in final facial function. CONCLUSION: Synkinesis in Bell's palsy patients can be minimized if physiotherapy commences before synkinesis develops; appropriate neuromuscular retraining therapy timing is essential. A patient with sudden severe Bell's palsy should receive oral steroids as soon as possible, along with physical therapy (including neuromuscular retraining therapy) within 3 months, to minimize synkinesis just before synkinesis onset.

Objectifying the Role of the Depressor Anguli Oris Muscle Using High-Resolution Ultrasound: A Prospective Study.

BACKGROUND: In the setting of facial palsy, synkinesis of the depressor anguli oris (DAO) muscle is a common pathology, impairing dynamic and resting facial symmetry.In this prospective study, the authors used high-resolution ultrasound (HRUS) to evaluate the morphologic features of DAO and to quantify bilateral differences in DAO cross-sectional diameter (CSD) in individuals with unilateral synkinesis. METHODS: From June of 2020 to May of 2021, 30 patients (19 women, 11 men) with clinically diagnosed unilateral synkinesis underwent evaluation with HRUS. DAO CSD was measured bilaterally, 1 cm inferior to the modiolus, in both the resting and smiling positions. RESULTS: The Sunnybrook Facial Grading System Synkinesis Score was 6.20 ± 2.48 (range, 0 to 10). DAO CSD at rest measured 2.41 ± 0.67 mm (range, 1.40 to 4.00 mm) on the control side and 2.66 ± 0.98 mm (range, 1.60 to 5.10 mm) on the affected side. On the control side, DAO CSD was reduced by -0.19 ± 0.43 mm (range, -1.10 to 1.12 mm) during smiling. In contrast, the synkinetic DAO CSD increased by 0.64 ± 0.38 mm (range, 0.00 to 1.59 mm) ( P < 0.001) with animation. The pattern of increased CSD in synkinetic DAO muscles and decreased or unchanged CSD on the control side during smiling was identified in 70% of patients. CONCLUSIONS: HRUS demonstrates increased CSD in synkinetic DAO muscles during active smiling. The opposite is true for DAO muscles on the control side, which exhibit decreased CSD with animation. HRUS can be performed preoperatively to objectify DAO dysfunction and guide targeted therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Modified Selective Neurectomy for Post Facial Paralysis Synkinesis Smile Dysfunction.

Following incomplete facial nerve injury, patients may develop aberrant facial nerve reinnervation, which can result in facial synkinesis. The treatment goals for patients with postfacial paralysis synkinesis are to improve resting oral commissure position, oral competence, facial and cervical tightness, and smile symmetry and spontaneity. Modified selective neurectomy of the facial nerve as described by Azizzadeh and colleagues is a targeted surgical method that allows the surgeon to eliminate the antagonist movements of the face and allow the favorable movements of the face to predominate, resulting in a more natural smile.