Evaluation of Long-Term Surgical and Patient-Reported Outcomes after Pediatric Facial Reanimation.

BACKGROUND: Outcomes of pediatric facial reanimation beyond 10 years are not known. This cross-sectional study evaluated long-term surgical and patient-reported outcomes of adults who underwent smile reconstruction as children with either a cross-face nerve graft (CFNG) or masseter nerve transfer at least 10 years previously. METHODS: Commissure excursion was quantified with FACE-Gram software at 3 time points: preoperatively, early postoperatively within 2 years, and at long-term follow-up. Patient-reported outcomes were evaluated with validated questionnaires (Facial Clinimetric Evaluation Scale, FACE-Q 1.0) and thematic analysis of semistructured interviews. Results are reported as median (interquartile range [IQR]). RESULTS: A total of 42 patients were included (26 women and 16 men). Median long-term follow-up was 19.3 years (IQR, 8.8 years) for CFNG and 17.6 years (IQR, 5.8 years) for masseter nerve transfer. For both groups, commissure excursion increased significantly from preoperative to early postoperative time points and remained stable at long-term follow-up (P < 0.0001). Commissure excursion at long-term follow-up between the 2 groups was not significantly different (CFNG, 5.0 mm [IQR, 9.4 mm]; masseter nerve transfer, 8.4 mm [IQR, 4.1 mm]); P > 0.05). For patient-reported outcomes, median Facial Clinimetric Evaluation Scale score was 72 of 100, and 95% of respondents agreed with the statement "I am pleased with the result" on the FACE-Q 1.0. Overall quality of life was rated at 7 of 10 or greater by 97% of participants, and all participants would recommend the surgery to other children. CONCLUSIONS: Pediatric facial reanimation with CFNG or masseter nerve transfer reliably improves commissure excursion with longevity beyond 10 years. Adult patients report overall high satisfaction and social functioning.

Infants' salivary oxytocin and positive affective reactions to people.

Oxytocin is a neuropeptide positively associated with prosociality in adults. Here, we studied whether infants' salivary oxytocin can be reliably measured, is developmentally stable, and is linked to social behavior. We longitudinally collected saliva from 62 U.S. infants (44 % female, 56 % Hispanic/Latino, 24 % Black, 18 % non-Hispanic White, 11 % multiracial) at 4, 8, and 14 months of age and offline-video-coded the valence of their facial affect in response to a video of a smiling woman. We also captured infants' affective reactions in terms of excitement/joyfulness during a live, structured interaction with a singing woman in the Early Social Communication Scales at 14 months. We detected stable individual differences in infants' oxytocin levels over time (over minutes and months) and in infants' positive affect over months and across contexts (video-based and in live interactions). We detected no statistically significant changes in oxytocin levels between 4 and 8 months but found an increase from 8 to 14 months. Infants with higher oxytocin levels showed more positive facial affect to a smiling person video at 4 months; however, this association disappeared at 8 months, and reversed at 14 months (i.e., higher oxytocin was associated with less positive facial affect). Infant salivary oxytocin may be a reliable physiological measure of individual differences related to socio-emotional development.

Infants' facial electromyographic responses to the sight of emotional interpersonal touch.

Adult studies have shown that observed interpersonal touch provides crucial information about others' emotional states. Yet, despite the unique communicative function of touch during development, very little is known about infants' sensitivity to the emotional valence of observed touches. To investigate this issue, we measured facial electromyographic (EMG) activity in response to positive (caress) and negative (scratches) observed touches in a sample of 11-month-old infants. Facial EMG activity was measured over the zygomaticus major (ZM) and corrugator supercilii muscles, respectively involved in positive (i.e., smiling) and negative (i.e., frowning) facial expressions. Results have shown distinct activations of the ZM during the observation of scratches and caresses. In particular, significantly greater activation of the ZM (smiling muscle) emerged specifically in response to the observation of caresses compared to scratches. Our finding suggests that, in infancy, observed affective touches can evoke emotional facial reactions.

Changes in Perceived Emotions in Facial Paralysis Patients After Depressor Anguli Oris Excision.

OBJECTIVES: Depressor anguli oris (DAO) excision can improve clinician-graded, objective, and patient-reported smile outcomes in patients with nonflaccid facial paralysis (NFFP). However, no prior research has studied changes in perceived emotions after surgery. This study quantifies changes in perceived emotions with smiling after DAO excision in the largest case series presented to date. METHODS: Prospectively collected data from patients with NFFP who underwent DAO excision at a tertiary care facial nerve center were reviewed. Patient-reported, clinician-graded, and objective smile metrics were compared before and after surgery. Videos of faces at rest and while smiling were analyzed by artificial intelligence-derived facial expression analysis software to quantify perceived emotions. RESULTS: Sixty-eight patients underwent isolated DAO excision between August 2021 and August 2023. Patients conveyed significantly more perceived happiness with smile and at rest after surgery (p < 0.001 and p = 0.012, respectively). DAO excision improved oral commissure excursion (p < 0.001), dental show (p < 0.001), and smile angle (p < 0.001) symmetry. Patients reported significant improvements in smiling and social function after surgery. CONCLUSIONS: This study demonstrates DAO excision increases perceived happiness conveyed by patients with NFFP while smiling and at rest. It confirms improved objective, clinician-graded, and patient-reported smile outcomes after surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:4028-4035, 2024.

Eyelid retraction during smiling in a patient with monocular congenital ptosis: a case report.

BACKGROUND: Blepharoptosis is a common symptom in ophthalmology clinic, but eyelid retraction when smiling in a ptosis eye is a rare manifestation. Here we report a novel manifestation that eyelid retraction during smiling in a patient with monocular congenital ptosis. CASE DESCRIPTION: A 10-year-old girl with isolated and mild unilateral congenital ptosis showed eyelid retraction in ptotsis eye when smiling together with a lid lag on downgaze. She didn't have any systematic and ocular diseases other than myopia and astigmatism.Eyelid retraction during smiling is 5 mm, resulting in a significant difference in the height of bilateral palpebral fissures.As for ptosis, is mild.The margin to reflex distance 1 is 1.0 mm on the right eye(ptosis eye) and 3.0 mm on the left eye. A lid lag of 1.0 mm on downward gaze was noted on the right, she could close her eyes fully while sleeping.The ice pack test, laboratory test for thyroid function, whole-exome sequencing (WES) and magnetic resonance imaging(MRI) of the orbital and ocular motor nerves showed normal results.Her symptoms alleviated after 6 months, with the retraction of the right upper eyelid when smiling was approximately 3 mm, thus the difference in the palpebral fissure height when smiling was smaller than that at the initial presentation. CONCLUSION: Blepharoptosis may accompanied with abnormal innervation like eyelid retraction, this phenomenon can be alleviated with age.The results of the levator muscle function test should be carefully examined to determine whether it is ptosis in an impaired innervation eyelid.

Smile dynamics: A comparative study of Fijians and NZ Europeans.

BACKGROUND: The Fijian 'Bula Smile' is often described as the world's friendliest; however, its description remains anecdotal. OBJECTIVE: This study aimed to describe and compare the dynamics of Fijians' smiles with those of New Zealand Europeans. METHODS: An observational study was conducted on two ethnic groups, Fijians (FJ; N = 23) and New Zealand Europeans (NZ; N = 23), age- and gender-matched. All participants were asked to watch amusing videos, and their reactions were video recorded. The videos were analysed by software to assess the frequency, duration, intensity and genuineness of smiling episodes. Based on the Facial Action Coding System, Action Unit 6 (AU6-cheek raiser), Action Unit 12 (AU12-lip corner puller) and Action Unit 25 (AU25-lips apart) were assessed. Data were analysed by generalised linear models after adjusting for personality traits. RESULTS: Fijians smiled longer than New Zealand Europeans (+19.9%; p = .027). Mean intensity of AU6 (+1.0; 95%CIs = 0.6-1.5; p < .001), AU12 (+0.5; 95%CIs = 0.1-0.9; p = .008) and AU25 (+22.3%; 95%CIs = 7.3%-37.3%; p = .005) were significantly higher in FJ group than the NZ group. CONCLUSION: Smiling features of Fijians and New Zealanders showed objective differences, the most distinctive being a higher activation of the Duchenne's marker (AU6) in the Fijian group, which is regarded as a sign of smile genuineness.

Reading of ingroup politicians' smiles triggers smiling in the corner of one's eyes.

Spontaneous smiles in response to politicians can serve as an implicit barometer for gauging electorate preferences. However, it is unclear whether a subtle Duchenne smile-an authentic expression involving the coactivation of the zygomaticus major (ZM) and orbicularis oculi (OO) muscles-would be elicited while reading about a favored politician smiling, indicating a more positive disposition and political endorsement. From an embodied simulation perspective, we investigated whether written descriptions of a politician's smile would trigger morphologically different smiles in readers depending on shared or opposing political orientation. In a controlled reading task in the laboratory, participants were presented with subject-verb phrases describing left and right-wing politicians smiling or frowning. Concurrently, their facial muscular reactions were measured via electromyography (EMG) recording at three facial muscles: the ZM and OO, coactive during Duchenne smiles, and the corrugator supercilii (CS) involved in frowning. We found that participants responded with a Duchenne smile detected at the ZM and OO facial muscles when exposed to portrayals of smiling politicians of same political orientation and reported more positive emotions towards these latter. In contrast, when reading about outgroup politicians smiling, there was a weaker activation of the ZM muscle and no activation of the OO muscle, suggesting a weak non-Duchenne smile, while emotions reported towards outgroup politicians were significantly more negative. Also, a more enhanced frown response in the CS was found for ingroup compared to outgroup politicians' frown expressions. Present findings suggest that a politician's smile may go a long way to influence electorates through both non-verbal and verbal pathways. They add another layer to our understanding of how language and social information shape embodied effects in a highly nuanced manner. Implications for verbal communication in the political context are discussed.

Outcomes of Free Flap Transfer in Facial Reanimation: A Review.

Free functional muscle transfer is is an option for reanimating the face in chronic facial nerve paralysis. The optimal outcome in these patients is the ability to restore a spontaneous smile in response to emotion. We discuss the role of free functional muscle transfer in facial paralysis treatment, the choices of nerve used in reconstruction surgery, and the application of different types of muscle flaps in facial reanimation. In this paper, we review the relevant and up-to-date academic literature regarding the outcomes of free functional muscle flap transfer in facial paralysis patients.

A Case Series of Isolated Smiling Tremor: What Is the Phenomenology?

BACKGROUND: Five cases of tremor only upon smiling have been reported where no facial tremor is present at rest, when talking, or with full smile. CASES: This report highlights four cases of tremor upon partial smiling, discusses the phenomenology of smiling tremor, and reviews the current literature. Four subjects with lower facial tremor present only upon smiling underwent movement disorders evaluation with video. Tremor frequencies were determined by parsing the video clips into 1-second intervals and averaging the number of oscillations per interval and were determined to be high-frequency 8 to 10 Hz irregular facial tremors with harmonic variations upon moderate effort in all cases. Slight or full-effort smiling did not elicit facial muscle oscillations. Subjects had no other signs of tremor, dystonia, or parkinsonism on examination or in family history. CONCLUSIONS: Tremor upon smiling only, or isolated smiling tremor, is a unique task- and position-specific tremor of the facial musculature.

Correlation of 3D Morphometric Changes, Kinematics, and Muscle Activity During Smile.

OBJECTIVE: Knowing the morphological, kinematic, and electrophysiological parameters of the smile in healthy individuals may contribute to evaluating, planning, and monitoring the smile reanimation. This study aimed to determine the correlation between 3D morphometric changes, movement kinematics, and muscle activity in the facial soft tissue of healthy individuals. METHOD: In this cohort study, 20 volunteers were selected from healthy individuals with no facial disorders. During smiling, three-dimensional face scanning, facial motion capture, and surface electromyography (sEMG) were performed. The average displacement, velocity, and acceleration during facial movements were measured. The mean change in 3D surface morphometry and activation of the zygomaticus major were determined. RESULTS: The volunteers, comprising 10 males and 10 females, had a mean age of 24 ± 10 years; for female, mean age was 23 ± 5 years and for men 26 ± 13 years. Significant correlations were found between kinematic and morphometric data (r = 0.51, p < 0.001), sEMG and morphometric (r = 0.50, p < 0.001) data, and sEMG and kinematic data (r = 0.49, p < 0.002). The maximum acceleration occurred during approximately 65% of the muscle activation time and 64% of the peak muscle activation value. Additionally, the maximum velocity was reached at around 73% of the muscle activation time and 67% of the peak muscle activation value. Furthermore, the maximum displacement values were observed at approximately 88% of the muscle activation time and 76% of the peak muscle activation value. CONCLUSION: The findings may provide insights into the smile's functional parameters, contribute to understanding facial muscle-related disorders, and aid in improving the diagnosis and treatment of the smile. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3112-3119, 2024.

Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures.

BACKGROUND: In facial reanimation, dual-innervated gracilis free functional muscle transfers (FFMTs) may have amalgamated increases in tone, excursion, synchroneity, and potentially spontaneity when compared with single innervation. The ideal staging of dual-innervated gracilis FFMTs has not been investigated. We aim to compare objective long-term outcomes following one- and two-stage dual-innervated gracilis FFMTs. METHODS: Included were adult patients with facial paralysis who underwent either one- (one-stage group) or two-stage (two-stage group) dual-innervated gracilis FFMT with ≥1 year of postoperative follow-up. Facial measurements were obtained from standardized photographs of patients in repose, closed-mouth smile, and open-mouth smile taken preoperatively, 1 year postoperatively, and 3 years postoperatively. Symmetry was calculated from the absolute difference between the paralyzed and healthy hemiface; a lower value indicates greater symmetry. RESULTS: Of 553 facial paralysis patients, 14 were included. Five and nine patients were in the one- and two-stage groups, with mean follow-up time, respectively, being 2.5 and 2.6 years. Within-group analysis of both groups, most paralyzed-side and symmetry measurements significantly improved over time with maintained significance at 3 years postoperatively in closed and open-mouth smile (all p ≤ 0.05). However, only the two-stage group had maintained significance in improvements at 3 years postoperatively in paralyzed-side and symmetry measurements in repose with commissure position (median change [interquartile range, IQR], 7.62 [6.00-10.56] mm), commissure angle (median change [IQR], 8.92 [6.18-13.69] degrees), commissure position symmetry (median change [IQR], -5.18 [-10.48 to -1.80] mm), commissure angle symmetry (median change [IQR], -9.78 [-11.73 to -7.32] degrees), and commissure height deviation (median change [IQR], -5.70 [-7.19 to -1.64] mm; all p ≤ 0.05). In the between-group analysis, all measurements were comparable in repose, closed-mouth smile, and open-mouth smile (all p > 0.05). CONCLUSION: Long-term outcomes demonstrate that both one- and two-stage dual-innervated gracilis FFMTs significantly improve excursion, but only two-stage reconstruction significantly improves resting tone.

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.

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.

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.

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.

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.