The Influence of BIA-ALCL on the Use of Textured Breast Implant and its Placement: A Survey of Dutch Plastic Surgeons.

BACKGROUND: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and its association with macrotextured breast implants may have induced plastic surgeons to change their breast augmentation and breast reconstruction practice. OBJECTIVES: The aim of this study was to survey Dutch plastic surgeons about the effects of BIA-ALCL on their choice of breast implant texture and placement technique. METHODS: An online questionnaire was distributed to all members of the Dutch Association of Plastic Surgeons. Descriptive data were presented as frequencies and percentages. Technique alterations were analyzed by the marginal homogeneity test for paired nominal data. RESULTS: A total of 63 plastic surgeons completed the questionnaire. The majority of respondents altered their use of textured implants due to BIA-ALCL concerns for both breast augmentation and reconstruction (75.4% and 69.8%, respectively; both being statistically significant, P < .001). Microtextured and smooth/nanotextured breast implants are now most frequently used. BIA-ALCL did not influence the placement technique in breast augmentation and reconstruction (87.7% and 94.3%, respectively). Dual-plane breast implant placement is still the most favored technique for breast augmentation, and submuscular placement is still most favored for breast reconstruction. CONCLUSIONS: BIA-ALCL has had a significant impact on the use of macrotextured breast implants by Dutch plastic surgeons in both aesthetic and reconstructive breast surgery. Breast implant placement technique has not been affected.

Quality of Life 9 to 13 Years after Autologous or Alloplastic Breast Reconstruction: Which Breast Remains Best?

BACKGROUND: The aim of this study was to evaluate the long-term patient satisfaction and quality of life 9 to 13 years after autologous versus alloplastic breast reconstruction and compare the data to those of an earlier study. METHODS: This is a 9-year follow-up study of 92 women who underwent breast reconstruction (47 autologous and 45 alloplastic) between 2006 and 2010 and filled out the BREAST-Q questionnaire in 2010. Changes in BREAST-Q scores were analyzed by using a change score from baseline (2010) to follow-up (2019), which was presented by a mean change score with 95% confidence intervals. Linear regression analyses were performed to test which patient characteristics were related to the BREAST-Q change scores. RESULTS: The response rate at follow-up was 60% (25 autologous and 30 alloplastic). Responders at follow-up had a lower body mass index and had less frequently undergone unilateral breast reconstruction compared to the nonresponders. Women undergoing both autologous and alloplastic breast reconstruction had significantly decreased satisfaction with breasts (-4 points), satisfaction with outcome (-8 points), and satisfaction with nipples (-20 points) over time. None of the patient characteristics, including reconstruction technique, were related to the BREAST-Q change scores. CONCLUSIONS: Satisfaction with breasts, satisfaction with outcome, and satisfaction with nipples decreased slightly over time for women undergoing alloplastic and autologous breast reconstruction. Women undergoing autologous breast reconstruction seemed to remain more satisfied with their breasts 9 to 13 years after breast reconstruction compared to women undergoing alloplastic breast reconstruction. Because of the small sample size, conclusions should be carefully drawn. However, the results were in line with the expectations based on previous literature.

Determining breast volume preference among patients, plastic surgeons, and laypeople: Is there a perfect breast size?

BACKGROUND: The female breast comes in many different shapes and sizes. The literature remains inconclusive on the ideal breast size. This study aims to investigate and compare breast size preferences among three cohorts (patients, plastic surgeons, and laypeople) to provide a better understanding of Western European ideals. METHODS: Patients, plastic surgeons, and laypeople were interviewed using a survey containing three-dimensional simulations of nine females, each depicted using five simulations with increasing breast size (1 = natural breast without breast implants, 2 = moderate, 3 = moderate plus, 4 = high, and 5 = ultra-high). Linear regression models were performed to define statistically significant associations between preferred breast size and predictor variables. RESULTS: In total, 28 patients, 45 plastic surgeons, and 100 laypeople (50 males and 50 females) participated in this study. On average, patients (3.5 ± 0.7) preferred larger breast sizes compared to surgeons (3.0 ± 0.7) and laypeople (3.1 ± 0.8). The difference between patients and surgeons was statistically significant. Overall, males preferred larger breast sizes than women. Patients of older age and with a higher BMI preferred larger breast sizes, while higher educational level was significantly associated with smaller breast size preference. Female plastic surgeons would undergo breast augmentation, while male plastic surgeons and female lay participants seem more skeptical. CONCLUSIONS: Significant preferential differences exist between patients and surgeons. It is important for professionals to be aware of societal ideals and preferential differences to adequately consult patients and achieve more satisfactory results.

Automated Spontaneity Assessment after Smile Reanimation: A Machine Learning Approach.

BACKGROUND: Recreation of a spontaneous, emotional smile remains a paramount goal of smile reanimation surgery. However, optimal techniques to reliably restore spontaneity remain unknown. Dual automated machine-learning tools were used to develop an objective tool to analyze spontaneous smiling. The feasibility of this tool was tested in a sample of functional free muscle transfers. METHODS: Validated humorous videos were used to elicit spontaneous smiles. Automated facial landmark recognition (Emotrics) and emotion detection software (Affdex) were used to analyze video clips of spontaneous smiling in nine normal subjects and 39 facial reanimation cases. Emotionality quotient was used to quantify the ability of spontaneous smiles to express joy. RESULTS: The software could analyze spontaneous smiling in all subjects. Spontaneous smiles of normal subjects exhibited median 100 percent joy and 0 percent negative emotion (emotional quotient score, +100/0). Spontaneous smiles of facial palsy patients after smile reanimation, using cross-facial nerve graft, masseteric nerve, and dual innervation, yielded median emotional quotient scores of +82/0, 0/-48, and +10/-24 respectively (joy, p = 0.006; negative emotion, p = 0.034). CONCLUSIONS: Computer vision software can objectively quantify spontaneous smiling outcomes. Of the retrospective sample of cases reviewed in this study, cross-facial nerve graft-innervated gracilis functional free muscle transfer achieved a greater degree of emotionality during spontaneous smiling than masseteric or dually innervated transfer. Quantification of spontaneous smiling from standard video clips could facilitate future, blinded, multicenter trials with sufficient long-term follow-up to definitively establish the rates of spontaneity from a range of reanimation procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

A cross-sectional analysis of facial palsy-related quality of life in 125 patients: Comparing linear, quadratic and cubic regression analyses.

INTRODUCTION: Facial function correlates with quality of life in facial palsy. Previous studies have examined a linear relationship; based on clinical experience, we hypothesize a curved regression (i.e. quadratic or cubic) will be more fitting to show the correlation between quality of life and facial function. METHODS: We compared the fit of a linear regression model between Sunnybrook scores (facial function) and FaCE and FDI scores (quality of life) to a quadratic and cubic regression model in 125 patients cross-sectionally. RESULTS: A total of 125 patients were included, 53.6% female with a mean (standard deviation) age of 56.6 (16.7) and a median (interquartile range) duration of palsy of 6.6 (1.5; 18.3) years. The quadratic regression proved a significant improvement over a linear regression analysis in the model using the FaCE total score (linear R2 =.346, quadratic R2 = .378, p = .033) and the FDI physical score (linear R2 = .245, quadratic R2 =.276, p = .034). The cubic regression analysis was no significant improvement over a quadratic regression. DISCUSSION: The relationship between facial function and quality of life in facial palsy is not linear meaning that there is a lot of variation in QoL in cases with severe and moderate facial impairment. This is most applicable to patients suffering from post-paralysis synkinesis, proving the highly individually experienced burden of synkinesis. As the relationship is not linear it should not be included as such in future research studies.

Interpreting Quality-of-Life Questionnaires in Patients with Long-Standing Facial Palsy.

Objective(s): To interpret change in quality-of-life scores in facial palsy patients by calculating the smallest detectable change (SDC) and minimal important change (MIC) for the Facial Disability Index (FDI), Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Materials and Methods: The SDC, for individuals and groups, was calculated using previously collected test-retest data (2-week interval). The MIC (predictive modeling method) was calculated in a second similar facial palsy population using two measurements (1-1.5-year interval) and an anchor question assessing perceived change. Results: SDCindividual of FaCE was 17.6 and SAQ was 28.2. SDCgroup of FaCE was 2.9 and SAQ was 4.6 (n = 62). Baseline FaCE and SAQ scores were 43.3 (interquartile range [IQR]: 35.8;55.0) and 51.1 (IQR: 32.2;60.0), respectively. MIC for important improvement of FDI physical/social function, FaCE total, and SAQ total were 4.4, 0.4, 0.7, and 2.8, respectively (n = 88). MIC for deterioration was 8.2, -1.8, -8.5, and 0.6, respectively. Baseline scores were 70.0 (IQR: 60.0;80.0), 76.0 (68.0;88.0), 55.0 (IQR: 40.0;61.7), and 26.7 (IQR: 22.2;35.6), respectively. Number of participants reporting important change for the different questionnaires ranged from 3 to 23 per subscale. Conclusion: Interpreting change scores of the FDI, FaCE, and SAQ is appropriate for groups, but for individual patients it is limited by a substantial SDC.

Quality of Life of Adopted Chinese Versus Nonadopted Dutch Children with Cleft Lip and/or Palate: A Propensity Score Matched Analysis.

OBJECTIVE: To examine quality of life in internationally adopted children with cleft lip and/or palate (CL/P) versus non-adopted children with CL/P. DESIGN: Cross sectional study. SETTING: Multidisciplinary cleft team of a secondary and tertiary hospital in the Netherlands. METHODS: Parents of children under the age of 8 treated by the multidisciplinary cleft team of our institutions were asked to fill out a questionnaire containing demographic and clinical data and a validated parent proxy measure of cleft-specific quality of life instrument for children aged 0-8: the CleftChild-8. Adopted children were matched to non-adopted children using propensity score matching based on sex, age, type of cleft, if palatal surgery was completed and the level of education of the parent. CleftChild-8 scores were then compared between the matched samples of adopted and non-adopted children with CL/P. MAIN OUTCOME MEASURE(S): Differences in (sub)domain scores of the CleftChild-8. RESULTS: Most median CleftChild-8 scores of the adopted children (n = 29) were slightly lower compared to the 29 matched non-adopted children. A significant difference was seen for the domain score 'satisfaction with (operative) treatment' and 3 of the 13 subdomain scores: 'post-operative results', 'acceptance by siblings' and 'acceptance by family/friends'. CONCLUSIONS: By parent report, adopted children with CL/P experienced some areas of lower quality of life when compared to non-adopted children. Members of cleft teams should be aware of the problems associated with adoption and offer additional guidance and counseling to adopted children and their parents.

Associations Between Clinician-Graded Facial Function and Patient-Reported Quality of Life in Adults With Peripheral Facial Palsy: A Systematic Review and Meta-analysis.

Importance: Understanding how the quality of life of adults (≥18 years) with peripheral facial palsy can be estimated using clinician measures of facial function and patient-reported variables might aid in counseling patients and in conducting research. Objectives: To analyze associations between clinician-graded facial function and patient-reported quality of life in adults with peripheral facial palsy, compare associations between facial function and the physical and social functions of quality of life, and examine factors that might influence the associations. Data Sources: A literature search was conducted in PubMed, Embase, CINAHL, Web of Science and PsycInfo on June 4, 2020, with no restrictions on the start date. Study Selection: Twenty-three studies reporting an association between clinician-graded facial function and patient-reported quality of life in adults with peripheral facial palsy were included. Facial function instruments included the House-Brackmann, Sunnybrook Facial Grading System, and electronic clinician-graded facial function assessment. Quality-of-life instruments included the Facial Disability Index and Facial Clinimetric Evaluation Scale. Data Extraction and Synthesis: Data extraction and qualitative synthesis were performed according to the Meta-analysis of Observational Studies in Epidemiology guidelines. Record screening, data extraction, and quality assessments were done by 2 researchers independently. Data were pooled using random-effects models. Main Outcomes and Measures: The main outcome was the association between facial function and quality of life, quantified by Pearson r, Spearman ρ, or regression analysis. Results: In total, 23 studies (3746 participants) were included. In the 21 studies that reported on the sex of the cohorts, there were 2073 women (57.3%). Mean or median age ranged from 21 to 64 years and mean or median duration of palsy ranged from newly diagnosed to 12 years. Bell palsy (n = 1397), benign tumor (n = 980), and infection (n = 257) were the most common etiologic factors. Pooled correlation coefficients were 0.424 (95% CI, 0.375-0.471) to 0.533 (95% CI, 0.447-0.610) between facial function and Facial Clinimetric Evaluation Scale total, 0.324 (95% CI, 0.128-0.495) to 0.397 (95% CI, 0.242-0.532) between facial function and Facial Clinimetric Evaluation Scale social function, 0.423 (95% CI, 0.322-0.514) to 0.605 (95% CI, -0.124-0.910) between facial function and Facial Disability Index physical function, and 0.166 (95% CI, 0.044-0.283) to 0.208 (95% CI, 0.031-0.373) between facial function and Facial Disability Index social function. Conclusions and Relevance: Associations noted in this systematic review and meta-analysis were overall low to moderate, suggesting that only a small part of quality of life is explained by facial function. Associations were higher between facial function and physical function than social function of quality of life.

Beauty Is in the Eye of the Beholder: Esthetic Outcome Assessment in Smile Reanimation Surgery in Patients With Facial Palsy.

ABSTRACT: Layperson assessments are becoming increasingly important in the evaluation of surgical procedures of the face, including smile reanimation. In this study, the authors set out to answer 3 questions: (1) are esthetic scores more dependent on the assessor or the person that is being assessed, (2) how does smile reanimation change esthetic scores, (3) do sex and age of the patient and assessor explain some of the esthetic outcomes?Thirty-five assessors scored pre and postoperative photographs of 21 facial palsy patients undergoing smile reanimation. Linear mixed-effect models were used to investigate the effects of assessor and patient factors on esthetic outcome assessments, to examine changes after smile reanimation, and to determine whether sex and age explained part of the esthetic outcomes.Fifty-eight percent of variation in the esthetic scores can be explained by some assessors being more positive in their esthetic scoring compared to other assessors. Twenty-nine percent was attributed to patient baseline esthetic scores. Overall esthetic scores improved after smile reanimation. Sex and age of the patient and assessor could not explain variation in the esthetic scores.Esthetic appearance highly depends on "who is looking." These findings are important for preoperative counseling, and for those treating and educating patients with facial palsy.

Association of Socioeconomic, Personality, and Mental Health Factors With Health-Related Quality of Life in Patients With Facial Palsy.

Importance: Knowledge of factors associated with health-related quality of life in patients with facial palsy may aid in better interpreting outcomes of research and treatment. Objective: To identify factors associated with health-related quality of life in patients with facial palsy. Design, Setting, and Participants: The inclusion period for participants in this cross-sectional study at the University Medical Center Groningen, a tertiary referral center for facial reanimation surgery, was March 1 to June 1, 2019. Patients aged at least 18 years with facial palsy who had undergone surgery for facial palsy between January 1, 2007, and January 1, 2018, and patients visiting the outpatient clinic of the University of Groningen Department of Plastic Surgery for their facial palsy between March 1 and June 1, 2019, were also asked to participate. Of 276 patients invited, 145 gave informed consent. Twenty patients did not respond after consent, 3 patients withdrew from the study, and 1 patient was wrongly included. Main Outcomes and Measures: Health-related quality of life was measured using the Facial Clinimetric Evaluation Scale and the Facial Disability Index (physical score and social score). Facial function was assessed with the Sunnybrook Facial Grading System. Other variables were investigated using validated questionnaires, including the Duke University Religion Index, Ten-Item Personality Inventory, and Hospital Anxiety and Depression Scale. Multivariable linear regression analyses with stepwise backward selection were performed to identify associations with health-related quality of life. Because 44 Sunnybrook composite scores were missing, a sensitivity analysis was performed that excluded the Sunnybrook composite scores from the multivariable analysis. Results: In total, 121 patients with facial palsy were included; their median age was 62 years (interquartile range, 48-71 years), and 63 (52%) were women. Sunnybrook composite score (ß = 0.4; 95% CI, 0.2-0.5), extraversion (ß = 2.6; 95% CI, 0.4-4.8), and anxiety (ß = -2.4; 95% CI, -4.1 to -0.8) were associated with the Facial Clinimetric Evaluation Scale total score (R2 = 0.380; 95% CI, 0.212-0.548). The Sunnybrook composite score was associated with the Facial Disability Index physical score (ß = 0.2; 95% CI, 0.0-0.4) (R2 = 0.084; 95% CI, -0.037 to 0.205). Bilateral facial palsy (ß = -21.2; 95% CI, -32.3 to -10.1), extraversion (ß = 2.7; 95% CI, 1.3-4.1), conscientiousness (ß = 2.7; 95% CI, 0.2-5.2), emotional stability (ß = 3.3; 95% CI, 1.7-4.8), and depression (ß = -1.3; 95% CI, -2.5 to -0.1) were associated with the Facial Disability Index social score (R2 = 0.400; 95% CI, 0.262-0.538). In the sensitivity analysis, the Sunnybrook composite score was associated with age (Spearman ρ = -0.252). Conclusions and Relevance: Bilateral facial palsy, age, severity of facial palsy, mental distress, and personality traits should be taken into account in future research and treatment of patients with facial palsy.

Toward an Automatic System for Computer-Aided Assessment in Facial Palsy.

Importance: Quantitative assessment of facial function is challenging, and subjective grading scales such as House-Brackmann, Sunnybrook, and eFACE have well-recognized limitations. Machine learning (ML) approaches to facial landmark localization carry great clinical potential as they enable high-throughput automated quantification of relevant facial metrics from photographs and videos. However, the translation from research settings to clinical application still requires important improvements. Objective: To develop a novel ML algorithm for fast and accurate localization of facial landmarks in photographs of facial palsy patients and utilize this technology as part of an automated computer-aided diagnosis system. Design, Setting, and Participants: Portrait photographs of 8 expressions obtained from 200 facial palsy patients and 10 healthy participants were manually annotated by localizing 68 facial landmarks in each photograph and by 3 trained clinicians using a custom graphical user interface. A novel ML model for automated facial landmark localization was trained using this disease-specific database. Algorithm accuracy was compared with manual markings and the output of a model trained using a larger database consisting only of healthy subjects. Main Outcomes and Measurements: Root mean square error normalized by the interocular distance (NRMSE) of facial landmark localization between prediction of ML algorithm and manually localized landmarks. Results: Publicly available algorithms for facial landmark localization provide poor localization accuracy when applied to photographs of patients compared with photographs of healthy controls (NRMSE, 8.56 ± 2.16 vs. 7.09 ± 2.34, p ≪ 0.01). We found significant improvement in facial landmark localization accuracy for the facial palsy patient population when using a model trained with a relatively small number photographs (1440) of patients compared with a model trained using several thousand more images of healthy faces (NRMSE, 6.03 ± 2.43 vs. 8.56 ± 2.16, p ≪ 0.01). Conclusions and Relevance: Retraining a computer vision facial landmark detection model with fewer than 1600 annotated images of patients significantly improved landmark detection performance in frontal view photographs of this population. The new annotated database and facial landmark localization model represent the first steps toward an automatic system for computer-aided assessment in facial palsy. Level of Evidence: 4.

Three-Dimensional Stereophotogrammetry Assessment of Facial Asymmetry in Facial Palsy.

Three-dimensional stereophotogrammetry is not much used in assessing facial palsy and a comprehensive understanding of sources of variation in these measurements is lacking. The present study assessed intra- and interobserver reliability of a novel three-dimensional stereophotogrammetry measurement of facial asymmetry and examined sources of variation in these outcomes. Three photographs (rest, closed mouth smile, and maximum smile) were made of 60 participants, 30 facial palsy patients and 30 control subjects. All images were analyzed twice by 2 observers independently, to determine intra- and interobserver reliability. Variance component analysis was performed to investigate sources of variation in the outcomes. Intraobserver reliability was good with intraclass correlation coefficients ranging from 0.715 to 0.999. Interobserver reliability ranged from 0.442 to 0.929. Reliability of the smile image measurements was not clearly different from the rest images. Variation in measurement results was largely due to the status of a participant, facial palsy versus control. When splitting the sample, the facial expression was a major source of variation. Acceptable reliability of the proposed 3D facial asymmetry measurement was found, in facial palsy patients and control subjects. Interobserver reliability was marked less compared to intraobserver reliability. For follow-up data only one observer should assess 3D stereophotogrammetry measurements.

Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery.

IMPORTANCE: Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation. OBJECTIVE: To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies. DESIGN, SETTING, AND PARTICIPANTS: Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018. INTERVENTIONS: Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer. MAIN OUTCOMES AND MEASURES: Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips. RESULTS: This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter-driven or cross-face nerve graft-driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter-driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft-driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity. CONCLUSIONS AND RELEVANCE: Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve-driven transfers but not to the level of cross-face nerve graft-driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques. LEVEL OF EVIDENCE: 4.

In the Eye of the Beholder: Changes in Perceived Emotion Expression after Smile Reanimation.

BACKGROUND: Tools to quantify layperson assessments of facial palsy are lacking. In this study, artificial intelligence was applied to develop a proxy for layperson assessments, and compare sensitivity to existing outcome measures. METHODS: Artificially intelligent emotion detection software was used to develop the emotionality quotient. The emotionality quotient was defined as the percentage probability of perceived joy over the percentage probability of perceived negative emotions during smiling, as predicted by the software. The emotionality quotient was used to analyze the emotionality of voluntary smiles of normal subjects and unilateral facial palsy patients before and after smile reanimation. The emotionality quotient was compared to oral commissure excursion and layperson assessments of facial palsy patients. RESULTS: In voluntary smiles of 10 normal subjects, 100 percent joy and no negative emotion was detected (interquartile ranges, 0/1). Median preoperative emotionality quotient of 30 facial palsy patients was 15/-60 (interquartile range, 73/62). Postoperatively, median emotionality quotient was 84/0 (interquartile range, 28/5). In 134 smile reanimation patients, no correlation was found between postoperative oral commissure excursion and emotionality quotient score. However, in 61 preoperative patients, a moderate correlation was found between layperson-assessed disfigurement and negative emotion perception (correlation coefficient, 0.516; p < 0.001). CONCLUSIONS: Computer vision artificial intelligence software detected less joy and more negative emotion in smiles of facial palsy patients compared with normal subjects. Following smile reanimation, significantly more joy and less negative emotion were detected. The emotionality quotient was correlated with layperson assessments. The simplicity, sensitivity, and objectivity of the emotionality quotient render it an attractive tool to serve as a potential proxy for layperson assessment, an ideal outcome measure in facial palsy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Patient experience in nerve-to-masseter-driven smile reanimation.

INTRODUCTION: The nerve-to-masseter is one of the most frequently used neural sources in smile reanimation surgery. Very little information has been reported on patient experience with regard to reanimated smile usage and sequelae following transfer. The aim of this study was to quantify patient perception of nerve-to-masseter use in smile reanimation surgery. METHODS: An online questionnaire was developed based on the clinical expertise of our team, patient interviews, and existing questionnaires of facial palsy-related quality of life and temporomandibular joint dysfunction. All patients treated with nerve-to-masseter-driven smile reanimation surgery, both nerve transfers and muscle transplantations, between 2007 and 2016 with a valid email address were invited to participate. RESULTS: Of 171 operated patients, 122 with a valid email address were invited to participate. Seventy-one patients responded (63.4% female, mean age 51.1 years) after a median follow-up of 3.8 years. A voluntary smile while biting down at least "most of the time" was reported by 83.1% of patients; 46.5% reported ability to smile on the affected side without bite. A "normal" or "almost normal" spontaneous smile was reported in 23.9% of patients. A total of 18.3% of patients self-reported masseter muscle atrophy, and 1.4-14.1% reported temporomandibular joint dysfunction. Forty-one patients (57.7%) reported prandial movement of the face at least "most of the time," with 9 patients (12.7%) considering this bothersome. CONCLUSION: Patients report good voluntary smiling ability following nerve-to-masseter-driven smile reanimation surgery, with low rates of sequelae.

Parotidectomy in patients with head and neck cutaneous melanoma with cervical lymph node involvement.

BACKGROUND: Parotidectomy in melanoma of the coronal scalp and face with clinically involved cervical lymph node metastasis is based on predicted cervical lymphatic drainage described by O'Brien. METHODS: In total, 40 parotidectomies with en bloc therapeutic neck dissection were retrospectively analyzed. RESULTS: Lymphatic spread of melanoma to the parotid lymph nodes was observed in 10 of 40 specimens (25%). Eight of the 10 parotid-positive patients developed a recurrence vs 17 of the 30 parotid-negative patients (P = 0.28). There were no differences in overall survival, melanoma-specific survival, and disease-free survival between the parotid-positive and parotid-negative patients. CONCLUSION: Although in this series no survival differences were found, parotidectomy still merits a sustained role in therapeutic neck dissection procedures to improve regional control and to prevent facial nerve damage after surgery for a second relapse from occult metastases in the parotid.