Nerve to the zygomaticus major muscle: An anatomical study and surgical application to smile reconstruction.

Smile reconstruction using the branches that supply the zygomaticus major muscle as a motor source is an established procedure in facial reanimation surgery for facial paralysis. However, the anatomy of the nerve to the muscle remains unclear. Therefore, we herein examined the topographical anatomy of the nerve to the zygomaticus major muscle to obtain more detailed information on donor nerve anatomy. Preserved cadaver dissection was performed under a microscope on 13 hemifaces of 8 specimens. The branches that innervate the zygomaticus major muscle and their peripheral routes medial to the muscle were traced and examined. A median of four (ranges 2-4) branches innervated the zygomaticus major muscle. The proximal two branches (near the muscle origin) arose from the zygomatic branch, the second of which was the major branch. The distal branches (near the oral commissure) arose from the buccal branch or zygomaticobuccal plexus. The vertical distance from the caudal margin of the zygomatic arch to the major branch intersecting point was 19 ± 4.0 mm, while the horizontal distance parallel to the Frankfort plane was 29 ± 5.2 mm. The proximal two branches innervating the zygomaticus major muscle were detected in the majority of specimens. The anatomical findings obtained herein on the nerve to the zygomaticus major muscle will allow for more reliable donor selection in facial reanimation surgery.

Restoring the spontaneous smile through free functional muscle transfer. A systematic review and meta-analysis of the last twenty years' experience.

BACKGROUND: The recovery of the spontaneous smile has become a primary focus in facial reanimation surgery and its major determinant is the selected neurotizer. We aimed to compare the spontaneity outcomes of the most preferred neurotization methods in free functional muscle transfer for long-standing facial paralysis. METHODS: The Embase, Ovid Medline, and PubMed databases were queried with 21 keywords. All clinical studies from the last 20 years reporting the postoperative spontaneity rate for specified neurotization strategies [cross-face nerve graft (CFNG), contralateral facial nerve (CLFN), motor nerve to the masseter (MNM), and dual innervation (DI)] were included. A meta-analysis of prevalence was performed using Freeman-Tukey double arcsine transformation, I2 statistic, and generic inverse variance with a random-effects model. Risk Of Bias In Non-randomized Studies of Interventions and Newcastle-Ottawa scale were used to assess bias and study quality. RESULTS: The literature search produced 2613 results and 473 unique citations for facial reanimation. Twenty-nine studies including 2046 patients were included in the systematic review. A meta-analysis of eligible data (1952 observations from 23 studies) showed statistically significant differences between the groups (CFNG: 0.94; 95% confidence interval [CI], 0.76-1.00, CLFN: 0.91; 95% CI, 0.49-1.00, MNM: 0.26; 95% CI, 0.05-0.54, DI: 0.98; 95% CI, 0.90-1.00, P < 0.001). In pairwise comparisons, statistically significant differences were found between MNM and other neurotization strategies (P < 0.001 in CFNG compared with MNM, P = 0.013 for CLFN compared with MNM, P < 0.001 for DI compared with MNM). CONCLUSIONS: DI- and CLFN-driven strategies achieved the most promising outcomes, whereas MNM showed the potential to elicit spontaneous smile at a lower extent. Our meta-analysis was limited primarily by incongruency between spontaneity assessment systems. Consensus on a standardized tool would enable more effective comparisons of the outcomes.

The effect of various muscle transfer procedures on eye closure and blinking in longstanding facial palsy patients.

BACKGROUND: Facial palsy causes paralytic lagophthalmos, which remarkably deteriorates a patient's quality of life. In cases where denervation time is over 18-24 months (longstanding facial palsy), a free or pedicled muscle transfer is needed to replace the denervated orbicularis oculi muscle. PURPOSE: The purpose of this systematic review is to investigate the effect of various eye sphincter substitution procedures (free or pedicled muscle transfers) in longstanding facial palsy patients on eye closure and blink. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the Embase, Medline, Web of Science and Cochrane Library databases and Google Scholar. Our literature search yielded 4322 articles. Following a full-text review, 4 retrospective cohort studies and 21 case series were selected for this review. Meta-analyses using R package meta (version 6.5-0) were conducted. MAIN FINDINGS: All free and pedicled muscle transfers in this review showed an improvement in the scores and measurements on eye closure and blink. The pedicled temporalis muscle transfer was the procedure most commonly performed as eye reanimation surgery and showed consistent good results. Using the random effects model, the pooled effect of mean difference in lagophthalmos after gentle eye closure post-operatively versus pre-operatively (mm) in patients who received a pedicled (temporalis) muscle transfer was -6.19 (I2 = 85%, 95% CI: -7.89; -4.49) whereas it was -4.11 (I2 = 85%, 95% CI: -7.26; -0.95) for free (gracilis or platysma) muscle transfers. The pooled proportion of patients with complete eye closure after surgery was 0.69 (I2 = 49%, 95% CI: 0.54; 0.82) in patients who received a pedicled (temporalis) muscle transfer and 0.40 (I2 = 74%, 95% CI: 0.13; 0.74) in patients who received a free (platysma) muscle transfer. CONCLUSIONS: Unlike smile reanimation, dynamic eye closure and blink restoration are rather neglected topics in facial reanimation. The pedicled temporalis muscle transfer is often recommended as the first treatment of choice for eye reanimation in longstanding facial palsy patients since it is a reliable, straightforward procedure, that does not require complex microsurgery. However, with the advancements in the field of microsurgery, free muscle transfers are promising therapies, which may regenerate voluntary and spontaneous blinking.

Secondary dynamic midface reanimation with gracilis free muscle transfer after failed reconstruction attempt: A 15-year experience.

BACKGROUND: The quantitative outcome of secondary reanimation after a failed primary reconstruction attempt for facial paralysis is rarely reported in the literature. This study aimed to investigate the feasibility of secondary reanimation with gracilis free muscle transfer (GFMT) and whether this outcome is influenced by the primary reconstruction. METHODS: Twelve patients with previously failed static procedures (static group, n = 6), temporal muscle transfer (temporal transfer group, n = 2), and GFMT (GFMT group, n = 4) were all secondarily reanimated with GFMT. The clinical outcome was graded with the eFACE metric. The objective oral commissure excursion was measured with Emotrics, and the artificial intelligence software FaceReader evaluated the intensity score (IS) of emotional expression. RESULTS: The mean follow-up was 40 ± 27 months. The eFACE metric showed a statistically significant (p < 0.05) postoperative improvement in the dynamic and smile scores across all groups. In the GFMT group, oral commissure with smile (75.75 ± 20.43 points), oral commissure excursion while smiling with teeth showing (32.7 ± 4.35 mm), and the intensity of happiness emotion while smiling without teeth showing (IS of 0.37 ± 0.23) were significantly lower as compared with the static group postoperatively (98.83 ± 2.86 points, p = 0.038; 41.7 ± 4.35 mm, p = 0.025; IS 0.83 ± 0.16, p = 0.01). CONCLUSIONS: Our data suggest that secondary dynamic reconstruction with GFMT is feasible should the primary reconstruction fail. The secondary GFMT appears to improve the outcome of primary GFMT; however, the oral commissure excursion while smiling might be lower than that in patients who had static procedures as primary reconstruction.

Three-dimensional evaluation of symmetry in facial palsy reanimation using stereophotogrammetric devices: A series of 15 cases.

Facial palsy can severely compromise quality of life, significantly altering the harmony and symmetry of the face, which can be restored by surgical rehabilitation. The aim of the study was the quantification of facial symmetry following facial reanimation. Fifteen consecutive adult patients were surgically treated through triple innervation for reanimation of flaccid unilateral facial paralysis (contralateral facial nerve, masseteric nerve, and hypoglossal nerve) and fascia lata graft for definition of the nasolabial sulcus. In the preoperative stage and at least 11 months after the surgical treatment, three-dimensional facial images were recorded through stereophotogrammetry in a neutral (rest) position, and with Mona Lisa and full-denture (maximum) smiles. Labial commissure inclination relative to the interpupillary axis, and a surface assessment of local facial asymmetry at rest and while smiling were obtained for the upper, middle, and lower facial thirds. The angle between the interpupillary axis and the labial commissure significantly improved in post-surgical acquisitions, regaining symmetry at rest (t-test; p < 0.001). Facial symmetry increased significantly when passing from pre-to postsurgical facial scans, from the lower to the upper facial third, and from the full smile to the rest position (ANOVA; p < 0.001). After treatment, the full smile recovered more symmetry than the other two expressions. In summary, surgical treatment significantly reduced facial asymmetry, but this reduction differed significantly among the various animations and facial thirds. The results of this study confirmed clinical findings of significant static and dynamic improvements in facial symmetry after triple innervation reanimation surgery.

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.

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 Selective Trigeminal Nerve Motor Branching Transfer: an Preliminary Clinical Application for Facial Reanimation.

OBJECTIVE: To investigate the effectiveness and feasibility of selective trigeminal nerve motor branching in the repair of facial palsy. MATERIALS AND METHODS: The clinical data of patients with advanced facial palsy from 2016 to 2021 were retrospectively analyzed, including pictures and videos before and 18 months after surgery. The House-Brackmann grading system was used to evaluate facial nerve function before and after repair, and the symmetry scale of oral commissure at rest and Terzis' smile functional evaluation scale were used to qualitatively assess the symmetry of the mouth angle and smile function. The distance of oral commissure movement was assessed to evaluate the dynamic repair effect, and the FaCE facial muscle function scale was used to assess patients' subjective perception before and after surgery. RESULTS: A total of four patients were included in the study, all of whom showed signs of recovery of facial nerve function within six months. In all four cases, significant improvements were observed in House-Brackmann ratings, the smile function score and the symmetry scale of oral commissure at rest. Compared to the pre-operative period, the four patients demonstrated various degrees of eye-closing function recovery, and a significant improvement in oral commissure movement was observed ( P <0.001). FaCE scores also improved significantly after surgery ( P =0.019). CONCLUSION: Concurrent selective facial nerve repair with trigeminal branch-facial nerve anastomosis resulted in eye-closing function recovery while improving static and dynamic symmetry, yielding acceptable postoperative results.

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.

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

PURPOSE: In this study, facial symmetry was compared between the masseter-innervated and dual-innervated free multivector serratus anterior muscle transfer (FMSAMT) methods. METHODS: Eighteen patients with unilateral complete facial paralysis underwent facial reanimation surgery between April 2006 and July 2019. The masseter-innervated FMSAMT group (Group M, n = 8) underwent end-to-end coaptation with the ipsilateral masseter nerve in one stage. The dual-innervated FMSAMT group (Group D, n = 10) underwent end-to-end coaptation with the masseter nerve and end-to-side coaptation with the contralateral facial nerve via cross-face nerve graft. They were further divided into the one-stage (Group D1, n = 5) and two-stage (Group D2, n = 5) subgroups. The durations of periods until the first visible muscle contraction with clenching, first spontaneous smile, and the completion of resting tone were evaluated. The possibility of a spontaneous smile and symmetry of the midline and horizontal deviation at rest and during voluntary smiling were compared between each group. RESULTS: Groups M and D differed significantly in the possibility of a spontaneous smile and improvement rate of midline deviation and horizontal deviation at rest (p < 0.001, p < 0.001, and p = 0.001, respectively) but not in the improvement rate of midline and horizontal deviation during voluntary smiling. The duration of the period until the completion of resting tone was significantly shorter in Group D1 than in Group D2 (p = 0.048); however, the possibility of a spontaneous smile and the improvement rate of midline and horizontal deviation were not significantly different. CONCLUSIONS: Dual-innervated FMSAMT was effective in guaranteeing a symmetrical resting tone, voluntary smiling, and reproducing a spontaneous smile.

Donor nerve selection in free gracilis muscle transfer for facial reanimation. A systematic review and meta-analysis of clinical outcomes.

BACKGROUND: One of the critical factors in facial reanimation is selecting the donor nerve. The most favored neurotizers are the contralateral facial nerve with a cross-face nerve graft (CFNG) and motor nerve to the masseter (MNM). A relatively new dual innervation (DI) method has shown successful results. This study aimed to compare the clinical outcomes of different neurotization strategies for free gracilis muscle transfer (FGMT). METHODS: The Scopus and WoS databases were queried with 21 keywords. Three-stage article selection was performed for the systematic review. Articles presenting quantitative data for commissure excursion and facial symmetry were included in meta-analysis, using random-effects model. ROBINS-I tool and Newcastle-Ottawa scale were used to assess bias and study quality. RESULTS: One hundred forty-seven articles containing FGMT were systematically reviewed. Most studies indicated CFNG as the first choice. MNM was primarily indicated in bilateral palsy and in elderly. Clinical outcomes of DI studies were promising. 13 studies including 435 observations (179 CFNG, 182 MNM, 74 DI) were eligible for meta-analysis. The mean change in commissure excursion was 7.15 mm (95% CI: 4.57-9.72) for CFNG, 8.46 mm (95% CI: 6.86-10.06) for MNM, and 5.18 mm (95% CI: 4.01-6.34) for DI. In pairwise comparisons, a significant difference was found between MNM and DI (p = 0.0011), despite the superior outcomes described in DI studies. No statistically significant difference was found in resting and smile symmetry (p = 0.625, p = 0.780). CONCLUSIONS: CFNG is the most preferred neurotizer, and MNM is a reliable second option. Outcomes of DI studies are promising, but more comparison studies are needed to draw conclusions. Our meta-analysis was limited by incompatibility of the assessment scales. Consensus on a standardized assessment system would add value to future studies.

Lower Facial Nerve Nomenclature Clarification: Cervical Branch Controls Smile-Associated Lower Lip Depression and Dental Display.

OBJECTIVE: In head and neck ablative surgery, traditional teaching is that the key facial nerve branch to preserve along the plane of the lower border of the mandible is the marginal mandibular branch (MMb), which is considered to control all lower lip musculature. The depressor labii inferioris (DLI) is the muscle responsible for pleasing lower lip displacement and lower dental display during natural emotive smiling. STUDY DESIGN: To understand the structure/function relationships of the distal lower facial nerve branches and lower lip musculature. SETTING: In vivo extensive facial nerve dissections under general anesthesia. METHODS: Intraoperative mapping was performed in 60 cases, using branch stimulation and simultaneous movement videography. RESULTS: In nearly all cases, the MMb innervated the depressor anguli oris, lower orbicularis oris, and mentalis muscles. The nerve branches controlling DLI function were identified 2 ± 0.5 cm below the angle of the mandible, originating from a cervical branch, separately and inferior to MMb. In half of the cases, we identified at least 2 independent branches activating the DLI, both within the cervical region. CONCLUSION: An appreciation of this anatomical finding may help prevent lower lip weakness following neck surgery. Avoiding the functional and cosmetic consequences that accompany loss of DLI function would have a significant impact on the burden of potentially preventable sequelae that the head and neck surgical patient frequently carries.

Modified gracilis muscle flap in facial reanimation: U-shaped design.

BACKGROUND: Surgical treatment of long-term facial palsy has been reported using various techniques, including functioning muscle-free flaps. The free gracilis muscle flap is the most common because of its many advantages. Our study presents a modified way of shaping the gracilis muscle for transfer to the face to improve the restoration of natural smiles. METHODS: This retrospective study assessed 5 patients who received the classical technique and 43 patients who received modified, U-shaped, free gracilis muscle flap for smile reanimation from 2013 to 2018. The surgery is single-staged. Preoperative and postoperative photos were taken. Functional outcomes were evaluated using the Terzis and Noah score and the Chuang smile excursion score. RESULTS: The mean patient age at the time of operation was 31 years. The length of gracilis muscle harvested was 12-13 cm. Of the 43 patients who received U-shaped design-free gracilis muscle, results were excellent for 15 (34.9%), good for 20 (46.5%), and fair for 8 (18.6%) followed the Terzis and Noah score. The Chuang smile excursion score was 2 for 16.3%, 3 for 46.5%, and 4 for 37.2% of 43 patients. Of the 5 patients who underwent classical technique, there are no excellent results based on the Terzis and Noah score. The Chuang smile excursion score was only 1 and 2. CONCLUSIONS: The U-shaped modification to the gracilis muscle-free flap is a simple and effective technique to help restore a symmetrical and natural smile in patients with facial palsy.

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

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

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.

V to VII Nerve Transfer for Smile Reanimation.

Using the wording "facial reanimation," surgeons mean restoring movements to the paralyzed face. According to the condition of mimic muscle, facial palsy can be classified as recent (mimic muscle still alive) and chronic (atrophy of mimic muscle) palsy. The treatment is quite different because in the former group the mimic muscles can be still used so long as a new motor source would be connected to the damaged facial nerve. In the latter group, muscular transplantation is needed to substitute the atrophied mimic muscles of the middle part of the face. In both cases, the neural impulse that makes the muscles (mimic muscle in the former, transplanted muscle in the latter) move come from a new motor nerve. Nowadays, the masseteric nerve is widely used as a new motor source in recent facial reanimation; the same nerve has also a main role in the treatment of both chronic facial palsy where it is used as the new nervous stimulus for the new transplanted muscle and facial paresis where the nervous stimulus coming from the masseteric nerve is used to empower the stimulus coming from the injured facial nerve. The masseteric nerve can be usually connected directly to the facial nerve without the interposition of a nerve graft, with a faster reinnervation. Moreover, the use of the masseteric nerve gives no morbidity to the masticatory functions.

The evaluation of the effect of free gracilis muscle transfer on cheek tone and oral competence in long-standing facial paralysis of patients by using Blasco index.

PURPOSE: Smile and eyelid reanimation are generally emphasized in facial reanimation, but the loss of cheek tone provided by the buccinator muscle is not adequately addressed. The use of free gracilis muscle flap for facial reanimation has become widespread since it was used in head and neck reconstruction by Harii et al. The effect of free gracilis muscle transfer on drooling is not clearly defined in the literature. In our study, we aimed to evaluate the effect of free gracilis muscle transfer on drooling in patients with facial paralysis (FP) by using Blasco index. Smile function was overemphasized in the literature, but drooling was not evaluated. What happens to drooling after free functional muscle transfer was not clear, so this study was designed to evaluate improvement in drooling. PATIENTS AND METHODS: Drooling and smile were evaluated in 11 patients (4 male, 7 female) who underwent facial reanimation with a free functional gracilis muscle transfer (FFGMT), in long-standing FP. The mean age was 39.9 years (range 22-56 years). Etiology was idiopathic in two patients, trauma in five patients, and intracranial tumor in four patients. Photographs and video recordings were taken preoperatively and at the first year postoperatively. The muscle was stitched to the upper lip, corner of the mouth, lower lip and the preauricular region. Masseteric nerve was preferred as donor nerve. Smile restoration was evaluated according to the five-stage classification defined by Terzis and Noah. RESULTS: Flap dimensions differed from 12 cm× 5 cm to 15 cm× 6 cm. Oral intake was stopped for 5 days, and speaking was restricted postoperatively. Patients exercised for about 1 h starting from the postoperative third month. Patients were followed up for an average of 26.5 (14-48) months postoperatively. Postop courses were uneventful, and we did not observe any complications in these patients. Preoperative Blasco index score was 3 in 6 patients, 2 in 5 patients and the mean scores were 2.54 ± 0.52. Patients were followed for 1 year. No drooling was observed in the postoperative first year. The Blasco index score was 0 for all patients. The decrease in postoperative scores was found to be statistically significant (p < .01). Smile restoration was evaluated according to the five-stage classification defined by Terzis and Noah for facial reanimation after muscle transfer. Excellent results (grade 5) were obtained in 6 patients, good results (grade 4) in 4 patients and moderate results (grade 3) in 1 patient. CONCLUSION: Free functional gracilis muscle transfer improves chewing functions and prevents drooling. This case series reveals that FFGMT can be a good option to enable cheek tone in long-standing FP of patients.

Predicting Depressor Anguli Oris Excision Outcomes Using Local Muscle Block.

Introduction: Although depressor anguli oris (DAO) muscle block is a useful tool to help predict which patients will respond positively to myectomy, DAO excision outcomes have not been correlated with smile changes after muscle block. Objective: To compare changes in smile symmetry after DAO muscle block with changes after DAO myectomy. Methods: Nonflaccid facial paralysis patients undergoing DAO excision at a tertiary care facial nerve center were prospectively studied from August 2021 to June 2022. Dental show, oral commissure excursion, and smile angle at baseline, after DAO muscle block, and after myectomy, were quantified. Results: Twenty-three patients underwent DAO muscle block followed by myectomy. DAO excision produced improved dental show (p = 0.006) and oral commissure excursion (p = 0.024) symmetry compared with muscle block. A strong correlation exists between changes in oral commissure excursion symmetry after muscle block and after myectomy. Moderate correlations exist for changes in smile angle and dental show symmetry. Conclusion: Although DAO muscle block is a good predictor of smile symmetry after muscle excision, typically excision results in improved dental show and oral commissure symmetry compared with block.

Functional Outcome Comparison of Free Gracilis Muscle Anchoring Methods in Patients with Facial Paralysis: Upper Lip Red Line Incision versus Facelift Incision Approach.

BACKGROUND: The greatest challenge of a free-muscle transfer in facial reanimation surgery is anchoring muscle to perioral soft tissue. An additional incision provides a better way to anchor the transferred muscle but leaves a visible scar. Herein, we compared the functional and aesthetic outcomes in a conventional facelift incision approach with and without the addition of a red line incision. METHODS: This study included patients experiencing unilateral facial paralysis who underwent free gracilis transfer between December 2016 and December 2018. Anchoring through facelift incision with extended neck incision was performed in the control group, while a red line incision was added in the red line group by avoiding extended neck incision. Oral commissure excursion, upper lip and commissure height differences, and symmetry were measured. RESULTS: A total of 24 patients met the criteria and were included in this study. Of these, 10 patients were assigned to the red line group and 14 to the control group. The red line and control groups demonstrated a similar symmetry index in both resting (0.96 ± 0.18 and 0.92 ± 0.10, respectively; p = 0.435) and smiling (0.94 ± 0.12 and 0.91 ± 0.10, respectively; p = 0.314). However, the upper lip height difference demonstrated greater postoperative improvement (resting: 2.12 ± 1.13 vs. 3.92 ± 1.41 mm, p = 0.002, and smiling: 1.68 ± 0.88 vs. 3.41 ± 1.69 mm, p = 0.004, respectively). A scar could be easily concealed on the mucocutaneous line of the lip. CONCLUSION: This novel method for muscle anchoring in facial reanimation surgery allows surgeons to approach perioral muscle more directly. This leads to improved surgical results by securely anchoring the transferred muscles using a fixation point that is more medially located than in other approaches. Our method is effective and offers an improved surgical outcome for the free functional gracilis muscle transfer.

Commentary on: "Tri-Vector Gracilis Microneurovascular Free Tissue Transfer with Periocular Component to Achieve a Duchenne Smile in Patients with Facial Paralysis" by Byrne et al.

In this commentary, we review Dr. Byrne and colleagues' article "Tri-vector Gracilis Microneurovascular Free Tissue Transfer with Periocular Component to Achieve a Duchenne Smile in Patients with Facial Paralysis." The authors successfully demonstrate the feasibility of separating the gracilis muscle into three bellies while maintaining neuromuscular input to achieve restoration of lower lid movement during smile, resulting in a more natural appearing or "Duchenne smile." Although the concept of spontaneity remains controversial, beautiful smile outcomes are illustrated in the featured photograph and videos.